Harbor Villa Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 861 S. Harbor Blvd, Anaheim, California 92805
- CMS Provider Number
- 055742
- Inspections on file
- 34
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Harbor Villa Care Center during CMS and state inspections, most recent first.
Failure to offload heels and provide ordered pressure-relieving support was identified for two residents. One resident was observed without the ordered pump-equipped mattress and with both heels resting directly on the mattress despite orders to float the heels at all times. Another resident with blanchable heel redness was also observed with both heels touching the mattress instead of being floated as ordered, and staff verified the heels were not offloaded.
Medication Administration Errors Outside Orders: An LVN administered furosemide to one resident despite a hold parameter tied to low SBP, and another LVN gave heparin to a different resident without a physician order. Facility policy required medications to be given according to prescriber orders and verified against the right resident, medication, dose, time, and route. Both residents had capacity to make medical decisions, and the errors were confirmed during record review and staff interviews.
Food was not prepared and held at safe, appetizing temperatures for residents on pureed and regular diets. Pureed sweet potato yam, ham, and braised cabbage were placed in the oven well before the tray line, and a DSS stated food should not be prepared more than one hour before service to avoid loss of nutritional value. During a tray inspection, a regular diet tray included ham at 98 degrees Fahrenheit, and a resident with a fortified high-protein regular diet order stated the food did not taste good and was served cold.
Kitchen Food Storage and Sanitation Deficiencies: Food safety and sanitation guidelines were not followed for most residents who ate food prepared in the kitchen. Surveyors observed improperly stored and unlabeled food items, an expired opened spice, damaged and unsanitary utensils and equipment, a heavily marred cutting board, wet-stored pitchers, a dietary aide preparing food with uncovered hairy arms, and a rusting water pipe behind the dishwasher.
The facility failed to ensure informed consent was properly completed for psychotropic medications for two residents. One resident with moderate cognitive impairment had a single consent form covering aripiprazole, clonazepam, and lorazepam, with aripiprazole misclassified as an antidepressant and no separate consent or nonpharmacological interventions for each medication. Another resident with severe cognitive impairment had consent forms for mirtazapine and olanzapine that were not signed by the physician and also lacked separate consent and intervention documentation for each drug.
A cognitively intact resident had Vicks VapoRub ointment stored in an open bedside drawer and reported using it recently, but the record showed no MD order and no self-administration assessment for the medication. CNA and RN staff confirmed the ointment was at the bedside and stated it should not have been there, and an LVN verified the missing order and assessment.
Sharp Handrail in Hallway A: A handrail in one hallway was observed with an uneven surface, peeling paint, and exposed wood underneath. The handrail was sharp to the touch, and the Maintenance Director verified the findings during a concurrent interview.
The facility failed to properly monitor and document psychotropic medication use for two residents. One resident with severe cognitive impairment had orthostatic BP checks recorded with identical lying and sitting values, and the chart lacked monthly behavior summaries for mirtazapine and olanzapine. Another resident with moderate cognitive impairment had a psychiatrist’s order to discontinue clonazepam as part of a GDR, but the medication was not discontinued as ordered.
Failure to Incorporate PASARR Level II Recommendations Into Care Plan: A resident with schizophrenia had a PASARR Level II evaluation listing multiple services and monitoring needs, including psychotropic medication monitoring, counseling, psychiatry, and safety monitoring. The record did not show the recommendations were followed up or incorporated into the care plan, and the MDS Coordinator confirmed the care plan did not address the PASARR evaluation or its results.
A resident with insulin orders and another resident with moderate cognitive impairment had insulin care errors involving repeated use of the same abdominal injection sites instead of rotating sites. For one resident, regular human insulin was also omitted on several occasions when the sliding scale indicated 1 unit should have been given. Nursing staff verified the site rotation problems and the missed sliding scale doses, and the DON acknowledged the findings.
A resident with significant recent weight loss had a dietitian recommendation and physician order for CNA Helping Hands during meals, but staff did not remain with the resident to assist or encourage intake. The resident was observed eating independently with low intake, meal substitutes were not consistently offered, and a CNA said the resident refused help but did not document the refusal or notify the LVN in writing. The LVN confirmed the order, the weight loss, and that there was no documentation of refusal, physician notification, or IDT follow-up.
Missing PICC Line Admission Assessment Documentation: The facility failed to document PICC line assessments for a resident with a PICC in the R arm receiving IV vancomycin for infection. Facility policy required external catheter length to be obtained on admission, and staff stated PICC measurements were to be documented on the IV MAR or in progress notes, but the record did not show admission documentation of the PICC external length or arm circumference.
Incorrect Oxygen Flow Rate: A resident was observed with nasal cannula oxygen running at 2.5 L/min, while the physician's order was for 2 L/min PRN for shortness of breath. The DON verified the mismatch during observation and again during record review, and the resident's H&P noted the resident had capacity to understand and make decisions.
Improper Disposal of Liquid Medication: An LVN discarded excess liquid iron sulfate into the medication cart trash bin while preparing a dose for a resident, then repoured the medication in the correct amount. Facility records showed staff had been trained on proper medication disposal and that liquid medications were to be discarded in the designated waste container, not in the trash.
Improper Storage of Resident Medications: A resident’s ciclesonide inhaler was left unattended at the bedside, and another resident had a packet of Vitamins A&D ointment left on the bedside table. Staff confirmed both items should not have been left out, and the ointment was treated as medication even though no physician order was found in the MAR/order summary.
A resident was served carrots instead of the braised cabbage listed on the lunch menu and meal ticket. The DSS verified the substitution occurred because the kitchen ran out of cabbage. The resident said she was not told about the change and stated she liked cabbage.
Failure to Complete Legionella Risk Assessment: The facility failed to conduct a facility-wide risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the water system. Review of the Legionella Water Management Program and related water system documents showed only general color-coded descriptions of water entry, distribution, heating, and sewer systems, but no identification of stagnation, temperature fluctuations, pressure changes, high-risk growth areas, or water flow direction. The IP confirmed the assessment was not documented, and the DON acknowledged the findings.
Two residents did not have documentation showing they were offered required flu and pneumococcal vaccines or provided education on the benefits and potential side effects before refusing. One resident was competent and had refused both vaccines, while another was cognitively intact, past due for annual flu vaccination, and refused the flu vaccine. The IP verified the missing documentation, and the DON acknowledged the findings.
Failure to Document COVID-19 Vaccine Education Before Refusal: The facility did not document that two residents were offered education on the benefits and potential side effects of the seasonal COVID-19 vaccine before their refusals were recorded. One resident was competent and had not received the vaccine, while another was cognitively intact, had previously received the vaccine, and was past due for the next dose. The IP reviewed the records and could not find evidence that either resident had been educated before refusing the vaccine.
An LVN used a personal Omron BP machine, borrowed from another LVN, to obtain a resident’s BP before medication administration because the med cart had no BP machine or manual cuff. The machine was identified as personal equipment, not facility issued, and the DON stated the facility did not have the manufacturer’s instructions or calibrate the device to verify proper function or accurate readings.
Failure to Care Plan Bilateral Hand Skin Discoloration: A resident with severe cognitive impairment and an apixaban order for atrial fibrillation was observed with visible skin discoloration on both hands. Record review and staff interviews confirmed the discoloration was known to nursing staff, but no care plan was documented to address the condition or guide monitoring.
The facility failed to control resident access to razors and other sharp objects, resulting in one resident with depressive disorder inflicting multiple lacerations to the wrist using a razor and another resident with schizoaffective disorder and anxiety keeping two razors and two scissors in an unlocked bag in a closet. Staff confirmed that sharp items were not supposed to be stored in resident rooms, yet razors supplied by staff were found there. An RN also showed that additional razors were kept in an unlocked cart at a nurse station and in an unlocked drawer in an unlocked supply closet near common areas, making them easily accessible to residents.
Three residents were affected when the facility did not provide necessary care to prevent accidents, including a resident who left unsupervised and fell, and two residents who did not receive required post-fall neuro checks as outlined in their care plans. Staff confirmed that education on safety and completion of assessments were not documented as required.
The facility did not report or investigate an alleged physical altercation between two residents, despite staff being aware of the incident and facility policy requiring immediate reporting of abuse allegations. The DON confirmed the event should have been reported to authorities and thoroughly investigated.
A facility did not thoroughly investigate an alleged physical altercation between two residents, despite both being cognitively intact and staff being aware of the incident. Staff interviews confirmed the event was reported, but the DON could not provide evidence of an investigation, violating facility policy on abuse investigation and reporting.
Two residents were involved in an incident where one, who was confused, accidentally grazed another's cheek while being moved by staff. The facility did not initiate or update care plans for either resident to address the incident, despite both being cognitively intact and able to make decisions. The DON confirmed that care plan problems related to the event were missed and only addressed after the issue was identified during review.
A resident was discharged without the required physician documentation indicating the basis for discharge, as mandated by facility policy. Medical record review and staff interviews confirmed that the attending physician did not document the clinical justification for discharge prior to issuing the LCD, despite ongoing therapy needs noted in the resident's records.
A facility failed to ensure a resident was free from physical restraints without medical necessity. A soft mitten restraint was applied to a resident's left hand without a physician's order, necessary assessments, or informed consent. The resident, with a history of hemiplegia and cognitive impairment, was observed wearing the restraint without proper documentation or monitoring. Staff confirmed the lack of compliance with facility policies regarding restraint use.
The facility failed to provide necessary care for two residents, including not assessing or obtaining orders for supplemental oxygen, not following up on medication delivery, and not maintaining a humidifier. Staff interviews revealed communication lapses and policy non-compliance.
A facility failed to notify a physician when a resident's right leg showed signs of a change in condition, including being purplish and cold, which indicated a lack of circulation. Despite a care plan for non-healing cellulitis and a physician's order for treatment, the LVN did not follow up on notifying the physician due to being busy and unfamiliar with documentation procedures. The RN and interim DON confirmed the lack of documentation and notification, acknowledging the oversight.
A resident with multiple impairments and incontinence did not receive appropriate pressure ulcer care as the facility failed to follow physician's orders for wound treatment and did not develop a care plan for Stage 3 pressure injuries. The resident's elbow wounds were treated with Medihoney instead of the prescribed Santyl ointment without a physician's order, and no care plan was initiated for pressure injuries on the lower back and sacrum. The interim DON and Administrator acknowledged these deficiencies.
The facility failed to ensure residents were free from unnecessary psychotropic medications, lacking non-pharmacological interventions and proper monitoring. A resident was prescribed multiple psychotropic medications without evidence of non-pharmacological interventions or monitoring for side effects. Another resident was prescribed Xanax and Remeron without reassessment or informed consent, and PRN orders for two residents were not limited to 14 days. Additionally, informed consent for a resident was improperly obtained. The DON acknowledged these deficiencies.
The facility failed to maintain effective infection control practices, lacking monthly surveillance logs and accurate QA reports. The Infection Preventionist did not track residents according to Loeb's criteria and omitted those with infection symptoms not on antibiotics. Staff failed to perform hand hygiene during care, and Enhanced Barrier Precautions were not properly implemented. The IP admitted to insufficient training, contributing to the facility's inability to control infection transmission.
The facility failed to ensure safe self-administration of medications for three residents. A resident self-administered dorzolamide eyedrops without an assessment or physician's order. Another resident had a gabapentin capsule left by a nurse for later self-administration, also without proper assessment or order. A third resident applied Vicks VapoRub ointment without a physician's order for self-administration. These oversights risked inaccurate medication administration and potential adverse reactions.
The facility failed to ensure call lights were within reach for several residents, potentially delaying care and impacting well-being. Observations and interviews revealed that residents often could not access their call lights, requiring assistance from roommates or yelling for help. Staff confirmed these findings, indicating a systemic issue with call light accessibility.
The facility did not address concerns from Resident Council meetings regarding medication timing, snack availability, and CNA interactions. Issues were not communicated effectively to relevant departments, and documentation was inadequate, leading to unresolved resident concerns.
The facility failed to provide individualized activity programs for residents, impacting their engagement and satisfaction. A resident was unable to watch TV in her preferred language, while another resident's activity participation records were blank, indicating a lack of engagement. Additionally, Bingo games were disrupted due to staff needing to supervise smoking residents, leading to dissatisfaction among residents.
A facility failed to provide a resident with the prescribed thin liquid consistency diet, as the care plan was not updated to reflect the physician's order change from nectar to thin liquid. The resident, with severe cognitive impairment and a risk of aspiration, was observed with thin liquid at the bedside, contrary to the updated order. The DON and Administrator confirmed these findings.
The facility failed to provide necessary respiratory care for four residents, including improper application of a nasal cannula, lack of physician's order for oxygen, and inadequate storage of respiratory equipment. Observations revealed that oxygen cannulas and nebulizer masks were not stored in clean set-up bags, and required signage was missing. These deficiencies were confirmed by facility staff during interviews and observations.
A facility failed to accurately monitor a dialysis resident's fluid intake and output, leading to potential life-threatening conditions. The resident's medical records showed discrepancies between daily fluid intake and output and the Weekly Intake and Output Evaluation. Nursing staff estimated fluid output based on incontinent briefs, and dietary intake was assumed from food consumption percentages, not accurately measured. This practice did not align with physician's orders for fluid restriction, resulting in inaccurate monitoring of the resident's fluid status.
The facility failed to ensure that the Infection Preventionist (IP) and nursing staff had the necessary competencies for infection control. The IP lacked training, leading to errors in identifying infection types and documenting meetings. Additionally, CNAs and LVNs were not adequately trained in Enhanced Barrier Precautions (EBP), increasing the risk of improper infection control practices.
A facility failed to monitor a resident for side effects of Norco, an opioid medication, as required by their pain management policy. The resident, capable of making medical decisions, had an order for Norco for pain management, but no documentation was found regarding monitoring for adverse effects. A nurse confirmed the lack of documentation, and the DON acknowledged the issue.
A facility's medication error rate was found to be 23.33%, exceeding the acceptable limit of 5%. Errors included failure to assess vital signs before medication administration, not administering medications with food as required, and not administering prescribed medications despite signing them as given. These errors involved three LVNs and affected three residents, with the DON and Administrator acknowledging the findings.
A resident did not receive prescribed medications for depression, manic disorder, and enlarged prostate due to a failure in medication administration. The medications were not administered by an LVN, despite being signed off on the MAR, and the pharmacy had not refilled the prescriptions after the initial supply ran out. The DON and Administrator confirmed these findings.
The facility failed to ensure proper medication storage and labeling, with expired and improperly stored medications found during inspections. Medications were left unattended in residents' rooms, and some medications lacked accurate labeling or physician orders. These deficiencies were acknowledged by the DON and staff.
The facility failed to follow food safety and sanitation guidelines, with wet coffee pots stored improperly, unsanitary kitchen equipment, and a lack of backflow prevention in the food preparation sink. The CDM and Maintenance Director confirmed these deficiencies.
A facility failed to ensure proper documentation and scheduling of hospice services for a resident. The hospice visit calendar was missing from the resident's medical record, and there was no accurate documentation of hospice staff visits. Interviews with staff confirmed the lack of verification of hospice visits and adherence to the plan of care, posing a risk for delayed hospice care.
The facility failed to implement its Antibiotic Stewardship Program effectively, as the IP could not provide documentation that physicians were notified about residents prescribed antibiotics without meeting Loeb's Criteria. This oversight was acknowledged by the DON, highlighting a lapse in the program's implementation, which could lead to inaccurate infection identification and inappropriate treatment.
A facility failed to provide a clean and homelike environment for a resident, as chipped paint was observed on the wall by the resident's bed. The Maintenance Director was unaware of the issue, while a CNA admitted to noticing the chipped paint for a week but forgot to report it. The Administrator and DON were informed and acknowledged the findings.
A facility failed to notify a resident's representative of the bed hold policy upon the resident's transfer to a hospital. The facility's policy requires written notification of bed hold rights, but there was no documentation for this in the resident's medical record. Staff interviews confirmed the oversight, and the DON acknowledged the deficiency.
Failure to Offload Heels and Provide Ordered Pressure-Relieving Mattress
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for two residents who were reviewed for pressure injuries. Resident 10 had physician orders for a pressure-relieving mattress with a pump and to offload or float both heels at all times for skin management. On observation, the resident was lying on a mattress without a pump, and both heels were covered with dressings and resting directly on the mattress rather than being floated or offloaded. A nurse verified the mattress did not have a pump and the heels were not floated, and stated the resident previously had a pump on the mattress but another resident needed it. Resident 104 had physician orders to apply A&D ointment to blanchable redness on both heels and to offload or float both heels every shift for skin management. On observation, the resident was lying in bed with both heels resting directly on the mattress and not floated. A nurse verified the heels were touching the mattress and stated the resident had not yet been assessed since the start of the shift. Later, another staff member again verified the heels were directly touching the mattress and not offloaded, and stated she would reposition the resident.
Medication Administration Errors Outside Orders
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when medications were administered outside of physician orders or without an order. Facility policy stated medications are to be administered in accordance with prescriber orders, including any required time frame, and the medication administrator is to verify the right resident, right medication, right dosage, right time, and right route before giving the medication. For one resident, an LVN administered furosemide 40 mg even though the physician order directed that the medication be held if systolic blood pressure was less than 110 mmHg. Before administration, the resident's blood pressure was 103/68 mmHg. The LVN later verified that the medication had been given despite the ordered hold parameter and stated it should not have been administered because the blood pressure was below the ordered threshold. The resident's history showed capacity to understand and make decisions, and the order was for furosemide for bilateral lower extremity edema. For another resident, an LVN administered heparin injection to the right upper quadrant of the abdomen even though there was no physician order for heparin in the resident's MAR or order summary. The LVN later verified there was no order for the heparin injection and stated he made a mistake and administered the medication to the wrong resident. The LVN also stated he had not checked the MAR thoroughly and had confused the last injection site for another medication with the heparin site. The resident had capacity to make medical decisions, and the physician was notified after the error was identified.
Food Served at Improper Temperatures
Penalty
Summary
Food was not prepared in a manner that conserved nutritive value and maintained safe, appetizing temperatures for residents on pureed and regular diets. The facility’s Food Preparation and Service policy stated that food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices and that proper hot and cold temperatures are maintained during food distribution and service. However, during observation of puree food preparation, pureed sweet potato yam, pureed ham, and pureed braised cabbage were placed in the oven between 1007 and 1016 hours, with the oven set at 200 degrees Fahrenheit, and remained there when checked at 1120 hours. The Director of Social Services stated the food tray line would start at 1200 hours and that food should not be prepared more than one hour before tray line to prevent loss of nutritional value. The deficiency also affected regular diet service. The facility’s Diet Type Report showed 45 residents consumed Regular Diet Texture prepared in the kitchen. Resident 39, who had a physician’s order for a fortified high protein no added salt regular texture, thin consistency diet with large portions at breakfast to increase caloric intake, stated the facility food did not taste good and was served cold during an observation. During a test tray inspection, the regular diet tray included ham that was observed at 98 degrees Fahrenheit, and the DSS verified that the ham was not warm enough. The resident’s H&P showed the resident was competent and able to make decisions.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
Food safety and sanitation guidelines were not followed for 81 of 87 residents who ate food prepared in the kitchen. During the initial kitchen tour with the DSS, oatmeal was observed stored in an aluminum container with a broken lid and torn plastic liner, and ground cinnamon had no open date. An opened bottle of ground ginger spice was also observed with a use-by date of 3/27/26. The DSS verified these findings and stated the oatmeal should have been stored in a sealed container, the cinnamon should have been stored, dated, and labeled, and the expired ginger should have been discarded. Additional kitchen observations showed multiple equipment and sanitation concerns. Two spatulas had chipped red handles, a food strainer had brownish-orange material resembling rust, and a frying pan had deep scratches with the non-stick surface worn away. One cutting board was heavily marred and fuzzy with knife marks, eight water pitchers were stored wet on a wet shelf, and one dietary aide was observed preparing pancake syrup with hairy arms uncovered. A water pipe behind the dishwasher was also observed peeling with brownish-orange material resembling rust, and the Maintenance Director confirmed the finding.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure residents or their representatives were informed in advance of proposed psychotropic medication treatment for two residents reviewed for unnecessary medications. For one resident with moderate cognitive impairment, the facility used a single informed consent form for aripiprazole, clonazepam, and lorazepam, and the aripiprazole was classified as an antidepressant on the consent form. The record did not show separate informed consents or separate nonpharmacological interventions for each of those medications. For the second resident, who had severe cognitive impairment, the informed consent forms for mirtazapine and olanzapine did not show that the physician signed them. The facility also did not have separate informed consent and nonpharmacological interventions for the mirtazapine and olanzapine medications. The resident’s orders showed mirtazapine was given at bedtime for depression with poor oral intake and olanzapine was given at bedtime for schizoaffective episodes manifested by outburst without reason, with nonpharmacological approaches listed in the orders. During interviews and record review, RN 1 verified the single consent form used for the first resident’s three medications and the classification of aripiprazole as an antidepressant. The SSD stated she was not aware the informed consent should have only one medication listed and said she would implement one informed consent per medication. RN 2 verified the second resident’s consents had two psychotropic medications on each form, acknowledged the physician signatures were missing, and stated separate informed consent and nonpharmacological approaches should have been used so it was clear which interventions applied to each medication. The DON was informed and acknowledged the findings.
Unassessed bedside medication found in resident drawer
Penalty
Summary
The facility failed to ensure that one resident was assessed for self-administration of medication. During the initial tour, a container of Vicks VapoRub ointment was observed inside an open drawer of the resident’s bedside cabinet. The resident was cognitively intact per the MDS, but the medical record review did not show a physician’s order for the Vicks VapoRub ointment or any self-administration assessment for that medication. During follow-up observation and interviews, the resident stated she had used the Vicks VapoRub ointment two days earlier. CNA 3 confirmed the ointment was in the open bedside drawer and stated the resident was not allowed to have medication in her cabinet or bedside table. RN 3 also verified the ointment was at the bedside and stated it should not have been there because it was considered a medication. LVN 1 confirmed there was no physician’s order and no self-administration assessment for the ointment and stated the resident’s drawers should have been checked and staff or the resident should have notified the charge nurse if medication was kept at the bedside. The DON was informed and acknowledged the findings.
Sharp Handrail in Hallway A
Penalty
Summary
The facility failed to ensure a safe environment for residents, staff, and visitors in one of four hallways. During observation, the handrail in Hallway A was found to have an uneven surface, with peeling paint exposing the wooden surface underneath. The handrail was also felt to be sharp to the touch. A concurrent interview with the Maintenance Director confirmed these findings.
Unnecessary Psychotropic Medication Monitoring and GDR Failures
Penalty
Summary
The facility failed to ensure two residents were free from unnecessary psychotropic medication-related deficiencies. One resident had severe cognitive impairment and was ordered to have orthostatic blood pressures monitored while lying and sitting every Sunday, but the recorded lying and sitting blood pressures were identical on multiple dates. RN 1 verified the readings were the same and stated the resident should have been checked in the correct positions because accurate orthostatic readings were needed to identify hypotension and report concerns to the physician. For the same resident, orders were in place for mirtazapine at bedtime for depression manifested by poor oral intake and olanzapine at bedtime for schizoaffective episodes manifested by outbursts without reason. The medical record did not contain monthly behavior summary reports for January through March 2026 for either medication. RN 1 verified the missing summaries and stated they were needed to assess behavioral response, determine whether medication adjustments were needed, and determine medication effectiveness and whether dose reduction was appropriate. A second resident with moderate cognitive impairment had orders for clonazepam every 12 hours for anxiety manifested by undirectable verbal aggressive behavior, lorazepam as needed for anxiety, and aripiprazole at bedtime for bipolar disorder. The consultant pharmacist recommended assessing whether a GDR was clinically appropriate, and the psychiatrist documented that a GDR would be attempted and that clonazepam was to be discontinued. However, the order summary did not show clonazepam was discontinued. The SSD, psychiatrist, and RN 1 all verified the discontinuation order was not carried out.
Failure to Incorporate PASARR Level II Recommendations Into Care Plan
Penalty
Summary
The facility failed to ensure that PASARR Level II recommendations were followed and incorporated into the care of one resident with schizophrenia. The resident was admitted to the facility and had diagnoses including schizophrenia; the medical record also showed a physician order for haloperidol 1 mg at bedtime for schizoaffective disorder. A DHCS letter documented that a PASARR Level II evaluation had been completed by a licensed clinical psychologist and listed multiple personalized care recommendations, including psychotropic medication and education monitoring, mental health rehabilitation activities, ADL training/reinforcement, supportive services, psychotherapy/counseling, substance rehabilitative services, psychiatry consultation, neuropsychology consultation, internal medicine consultation, optometry consultation, social worker consultation, pain services consultation, sleep specialist consultation, smoking cessation, and safety monitors for falling and harm to self or others. Further review of the resident's medical record did not show documentation that these PASARR recommendations were followed up or incorporated into the resident's care. The resident's plan of care did not show a care plan developed to address the PASARR Level II recommendations. During interview and concurrent record review, the MDS Coordinator verified that documented evidence of follow-up could not be found and stated the care plan did not address the PASARR Level II evaluation or its results, although she stated the resident was receiving services recommended by the evaluation and that they were already part of the care plan. The DON was later informed and acknowledged the findings.
Insulin Site Rotation and Sliding Scale Dosing Errors
Penalty
Summary
The facility failed to provide insulin treatment and care in accordance with physician orders and its own insulin administration policy for two residents. For Resident 10, the record showed orders for glargine insulin at bedtime and regular human insulin before meals and at bedtime. Review of the location of administration record showed the insulin injections were given repeatedly in the same abdominal sites on consecutive administrations, including the LUQ and LLQ, rather than being rotated. For Resident 87, who had moderate cognitive impairment, the record showed an order for regular human insulin to be given by sliding scale before meals and at bedtime. The location of administration record showed the insulin was repeatedly administered in the same abdominal quadrants across multiple dates in February, March, and April 2026, with several consecutive doses documented in the same site. During interview, nursing staff verified that the site was not rotated multiple times and stated the site should have been rotated to prevent skin complications. Resident 87’s record also showed several instances where regular human insulin was not administered when the sliding scale indicated 1 unit should have been given, including at multiple scheduled times in February and March 2026. Nursing staff verified these omissions and stated the licensed nurse should have followed the insulin sliding scale dosing and reviewed it before giving the medication. The DON was informed and acknowledged the findings.
Failure to Provide Ordered Meal Assistance After Significant Weight Loss
Penalty
Summary
The facility failed to ensure that one sampled resident with significant recent weight loss received the ordered nutritional support and follow-up. The resident was competent and able to make decisions, and the medical record showed a weight decrease from 106 lbs. to 101 lbs. and then 100 lbs. over about one month, reflecting a loss of more than 5% of body weight. A dietary note documented the weight loss, the resident’s meal intake of 0-50-100%, and recommended CNA Helping Hands during meals. The interdisciplinary team agreed with that recommendation, and the physician entered an order for CNA Helping Hands with meals. Despite the order, the resident was observed eating without staff assistance or encouragement during meals. On one observation, a CNA set up the meal tray and left the room while the resident ate less than 50% of the meal. On another observation, the resident ate breakfast independently, did not eat the main entree, and consumed less than 25% of the tray. The record showed low intake for those meals, and meal substitutes were not offered at lunch and were refused at breakfast. During interview, the CNA stated the resident refused assistance and that she verbally notified the assigned LVN, but she did not document the notification. The LVN stated CNA Helping Hands meant the staff should remain with the resident during meals to assist and encourage intake, and verified the resident’s significant weight loss, the dietitian’s recommendation, and the physician’s order. The LVN also stated there was no documentation showing the resident’s refusal of assistance, no notification to the physician, and no follow-up by the dietitian or IDT. Another LVN stated he had not been notified of any refusals or low intake. The DON was informed of the findings and acknowledged them.
Missing PICC Line Admission Assessment Documentation
Penalty
Summary
The facility failed to ensure PICC line assessments were performed and documented for Resident 58, who was admitted with a PICC line inserted at an acute care hospital on 3/22/26 and had physician orders for IV vancomycin and PICC dressing changes. The resident’s H&P dated 3/23/26 showed he had the capacity to make medical decisions. On 4/7/26, the resident was observed with a PICC line in the right arm and stated he was receiving IV antibiotics for an infection. Facility policy titled PICC Dressing Change dated 3/2023 stated the external catheter length is obtained upon admission. During interview and record review on 4/8/26, LVN 2 stated the RN would obtain and document PICC measurements upon admission and every 7 days during dressing changes, including the external length to ensure the catheter remains in place. However, the medical record did not show documentation of the PICC external catheter length or arm circumference upon admission for Resident 58. The DON later verified these findings.
Incorrect Oxygen Flow Rate
Penalty
Summary
Facility failed to ensure necessary respiratory care and services were provided for Resident 44 when the resident did not receive the correct amount of oxygen via nasal cannula per the physician's order. On 4/7/26 at 0744 hours, Resident 44 was observed in the room with nasal cannula tubing in place and the oxygen concentrator turned on and set at 2.5 liters per minute. During a concurrent observation and interview at 1009 hours, the DON verified the concentrator was set at 2.5 liters per minute and stated the physician's order was for 2 liters per minute, and that licensed nurses are required to follow the ordered amount. Medical record review showed Resident 44 was admitted and later readmitted to the facility, and the H&P dated 3/30/26 documented that the resident had the capacity to understand and make decisions. The Order Summary Report dated 4/8/26 included a physician's order dated 3/30/26 for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. During a follow-up interview and record review on 4/9/26, the DON again verified the oxygen order was for 2 liters per minute via nasal cannula, and on 4/10/26 the Administrator and DON were informed of and acknowledged the findings.
Improper Disposal of Liquid Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when an LVN discarded liquid medication in the medication cart trash bin. During a medication administration observation for Resident 106, LVN 4 prepared 15 ml of liquid iron sulfate, stated the physician’s order was for 7.5 ml, and then poured the 15 ml dose into the medication cart trash bin before repouring the medication in the correct amount. LVN 4 stated that when liquid medications needed to be discarded, his normal process was to throw them in the trash bin. Facility records showed the facility had a policy for discarding and destroying medications and had provided education on proper medication disposal, including instruction that medications were not to be thrown in the trash can. The in-service attendance record showed LVN 4 attended the training. During follow-up interviews, LVN 4 stated he did not use the sharps container for liquid medications and later identified a waste container in the biohazard room where liquid medications were discarded, but said he had never used it. The DON and Administrator were informed of the findings and acknowledged them.
Improper Storage of Resident Medications
Penalty
Summary
The facility failed to ensure drugs, biologicals, and medical supplies were stored safely for two residents. Facility policy stated that medications are to be maintained in a clean, safe, sanitary manner and stored in an orderly way in cabinets, drawers, carts, or automatic dispensing systems, with each resident’s medications assigned to an individual holding area to prevent mixing medications of several residents. During the initial tour, Resident 6, who had been admitted to the facility and had capacity to understand and make decisions, was observed with a ciclesonide inhaler left unattended on top of the nightstand beside the bed. The inhaler remained at the bedside during a later observation while staff, residents, and visitors passed by, and a CNA entered the room to reposition the resident while the inhaler was still accessible. An LVN later verified the inhaler had been left unattended and stated it should have been stored in the medication cart. Resident 91, who was cognitively intact, was observed sitting in bed with a packet of Vitamins A&D ointment on the bedside table. The resident stated the treatment nurse applied the ointment to her skin. CNA 3 verified the packet was on the bedside table and stated the resident was not permitted to keep medications at the bedside. RN 3 also verified the ointment should not have been left out because it was considered medication. LVN 1 stated the packet should have been returned to the treatment nurse and that a licensed nurse should obtain a physician’s order before applying or storing the ointment for the resident. The resident’s April 2026 order summary did not show a physician’s order for the Vitamins A&D ointment.
Menu Item Not Followed for Resident Meal
Penalty
Summary
The facility failed to ensure the menu and recipes were followed for one resident who consumed food prepared in the kitchen. The report states that the facility’s menus were to be developed and prepared in advance, posted, and reviewed and approved by the dietitian, and that the lunch menu for Wednesday, 4/8/26 included baked ham, whipped sweet potatoes, braised cabbage, cornbread, and banana gelatin. Resident 14 had an order for a carbohydrate controlled, no added salt, regular texture, thin consistency, no caffeine, no decaf, fortified diet for a liberalized diet. On 4/8/26 at 1240 hours, the resident’s noon meal ticket and tray were observed in the kitchen and showed the ordered meal items, but the resident’s plate contained baked ham, whipped sweet potatoes, carrots, and cornbread instead of braised cabbage. During a concurrent interview, the DSS verified that diced carrots had been served because the facility ran out of braised cabbage. Later that day, the resident stated she had not been informed that she would receive carrots instead of cabbage and said she liked cabbage.
Failure to Complete Facility-Wide Legionella Risk Assessment
Penalty
Summary
The facility failed to ensure infection control practices were followed by not conducting a facility-wide risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the water system. The cited deficiency was based on interview, medical record review, facility document review, and facility policy review, and it involved the facility's Legionella Water Management Program, which stated it was intended to identify areas in the water system where Legionella bacteria can grow and spread and to reduce the risk of legionnaires disease. Review of the facility's Water System Flow Diagram showed color-coded water entry, cold-water distribution, heating components, hot-water distribution, and sanitary sewer systems. However, the document titled Areas Where Legionella Could Grow and Spread only repeated those general descriptions and did not identify areas of potential water stagnation, temperature fluctuations, pressure changes, high-risk locations for bacterial growth, or the direction of water flow or sections of piping where hazardous conditions could develop. During interview, the IP confirmed the document did not include those elements and was unable to provide documentation showing that a comprehensive risk assessment had been completed. The DON was informed and acknowledged the findings.
Failure to Document Vaccine Education and Offerings
Penalty
Summary
The facility failed to offer and provide required education on the benefits and potential side effects of the seasonal influenza and pneumococcal vaccines for two residents reviewed. Facility policies stated that residents without contraindications were to be offered influenza vaccine annually and pneumococcal vaccine as indicated, and that prior to vaccination the resident or legal representative was to receive information and education about the benefits and potential side effects of the vaccines. The report identified that Resident 8 was competent and able to make decisions, had not received pneumococcal or seasonal influenza vaccinations, and had refused both vaccines, but the medical record did not show that education was provided before the refusals. The report also identified that Resident 14 was cognitively intact, had previously received seasonal influenza vaccine, and was past due for the annual influenza vaccine, but had refused the seasonal influenza vaccine. The medical record did not show that Resident 14 was offered the vaccine or provided education regarding its benefits and potential side effects. During interview and concurrent record review, the IP stated the influenza vaccine should be offered every year and verified the findings, and the DON was informed and acknowledged the findings.
Failure to Document COVID-19 Vaccine Education Before Refusal
Penalty
Summary
The facility failed to ensure that residents were offered and provided education regarding the benefits and potential side effects of the seasonal COVID-19 vaccine before refusal was documented for two residents. Facility policy stated that each resident is to be offered the COVID-19 vaccine unless medically contraindicated or fully vaccinated, and that the resident or representative has the opportunity to accept or refuse the vaccine after receiving education about its benefits, risks, and potential side effects. Resident 8 was competent and able to make decisions, had not received the seasonal COVID-19 vaccine, and was documented as refusing it, but the medical record did not show that the resident was offered education about the vaccine before the refusal. Resident 14 was cognitively intact, had previously received a seasonal COVID-19 vaccine, was past due for the next dose, and was documented as refusing the vaccine, but the medical record also did not show that the resident was offered education regarding the benefits and potential side effects before the refusal. The IP reviewed the records and could not find documentation showing that either resident had been offered or educated regarding the 2025 seasonal COVID-19 vaccine, and the DON was informed of the findings.
Uncalibrated Personal BP Machine Used for Resident Assessment
Penalty
Summary
The facility failed to ensure resident care equipment was maintained in a safe operating condition when an LVN used a non-facility issued automatic BP machine to obtain a resident’s BP prior to medication administration. During the medication pass, the LVN used an Omron BP5100 machine borrowed from another LVN because the medication cart did not have a BP machine or manual BP cuff, only a stethoscope. The resident’s BP was recorded as 103/68 mmHg and the heart rate was 68 beats per minute. The BP machine was observed labeled with an individual’s name, and another LVN stated it was personal equipment and not facility issued. The Administrator verified the machine was not facility issued, and the DON stated licensed nurses were not supposed to use their personal BP machines brought from home. The DON also stated the facility did not have the manual or manufacturer’s guideline for the Omron BP machine and did not calibrate it to ensure it was working properly or had accurate measurements.
Failure to Care Plan Bilateral Hand Skin Discoloration
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan that reflected the individualized care needs of Resident 3. During the initial tour, Resident 3 was observed sitting in a wheelchair with visible skin discoloration on both hands. Review of the medical record showed Resident 3 was admitted to the facility, had severe cognitive impairment on the MDS assessment, and had a physician’s order for apixaban 5 mg twice daily for atrial fibrillation. Further review of the record did not show documented evidence that a care plan had been developed to address the skin discoloration on both hands. CNA 4 verified the bilateral hand discoloration and stated licensed nurses were aware of the bruise, but he did not know how it occurred. LVN 8 also verified the discoloration and stated Resident 3 was admitted with bruising on both hands and was taking apixaban, which could contribute to bruising. LVN 8 confirmed there was no care plan addressing the condition and stated a care plan should have been developed so staff could monitor the condition and prevent complications.
Failure to Secure Razors and Sharp Objects Accessible to Residents
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not adequately control resident access to sharp objects. One resident with a documented diagnosis of depressive disorder expressed suicidal ideation and was later found during nursing rounds with multiple self-inflicted lacerations on the left wrist and a razor in hand, stating he wanted to harm himself. This resident was transferred to an acute hospital for further evaluation and treatment of the self-inflicted injuries. The report does not indicate how this resident obtained the razor, and the Administrator acknowledged the facility did not know how the resident got it. Another resident, diagnosed with schizoaffective disorder and anxiety and documented as having decision-making capacity, was observed with a beard and stated he was independent with shaving. During an observation and interview in this resident’s room, the resident retrieved a personal bag from the closet that contained two razors and two pairs of scissors, which the resident stated had been supplied by facility staff. An LVN confirmed that sharp items were not supposed to be stored in residents’ rooms. Additionally, an RN demonstrated that razors for resident use were stored in an unlocked, transparent drawer cart at a nurse station and in an unlocked drawer inside an unlocked supply closet near common areas, all easily accessible to residents. The RN acknowledged that these razors were not secured and were easily accessible to residents.
Failure to Prevent Accidents and Complete Required Assessments
Penalty
Summary
The facility failed to provide necessary care and services to prevent accidents for three residents. One resident left the facility unsupervised after dinner without informing staff and was pulled by another resident on an electric chair. While passing over a gate frame, the resident's chair tilted, causing her to fall and land on her right shoulder. Although there were no head or skin injuries and vital signs were normal, the resident was transferred to an acute care hospital. The care plan for this resident included interventions such as educating her on the importance of informing staff before leaving the facility and explaining the risks of not doing so. However, there was no documented evidence that this education or explanation of risks was provided. Additionally, the resident's smoking assessment was not completed upon readmission, as verified by staff review. Two other residents experienced falls and were placed on care plans that required post-fall neurological checks for 72 hours. One resident was found sitting on the floor with no injuries, and the other was found lying on the floor after attempting to reach for a diaper, also with no injuries. Despite care plan interventions specifying neuro checks, medical record reviews for both residents failed to show any documented evidence that these assessments were completed following their falls. Staff interviews confirmed that neuro checks should have been performed and documented, but no such documentation was found. The Director of Nursing and other nursing staff verified the lack of documentation for both the education regarding leaving the facility and the required post-fall neuro checks. The facility's policies and procedures require comprehensive care planning, accurate assessments, and documentation of all relevant care and interventions, but these were not followed in the cases reviewed. These failures had the potential to negatively affect the health and well-being of the residents involved.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: For Resident 1, who was directly affected, corrective actions were taken immediately. On 8/1/25, the resident was re-educated by the DON and SS on the facility's out-on-pass policy, including the requirement to notify staff before leaving the premises. The charge nurse will monitor the signing in and out book. The resident was also informed of the potential dangers and/or risks associated with going out on pass, including the possibility of accident or injury. Specific safety concerns were addressed, such as nearby streets with vehicle traffic, and environmental hazards like uneven pavement, gravel, curbs, driveways, sidewalk cracks, steps, and stairs. This education was provided verbally and acknowledged in writing by the resident. A smoking assessment for Resident 1 was accurately completed by the LN per facility procedure, and all documentation was placed in the medical record on August 1, 2025. Residents 2 and 3 did not experience any harm as a result of the missed post-fall neuro checks. Both residents have since been discharged from the facility in accordance with their individual discharge plans. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On August 1, 2025, the Medical Records audited residents who have an order for going out on pass. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on providing/documenting unsupervised leave risk education, including the monitoring of the sign-in and out book for completeness and accuracy. On August 1, 2025, the Medical Records identified and audited the residents who smoke. All smoking assessments were audited for completeness and accuracy. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on smoking assessment completion at admission, re-admission, and quarterly. On August 1, 2025, the Medical Records audited residents with similar risk factors and confirmed timely neuro checks for the other fall case. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on following care plans and completing neuro checks after falls. What measures will be put in place or what systemic changes will the facility make to ensure that the deficient practice does not recur: To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, regarding their responsibility to initiate and document all resident education about the risks of leaving the facility without staff notification and monitoring the sign-in and out book. The RN Supervisor or designee reviews the resident signing in and out book daily for completeness and accuracy. To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, to complete smoking assessments for all identified smokers at admission, re-admission, and quarterly. Medical Records verifies weekly that all residents identified as smokers have a current smoking assessment for completeness and accuracy. The DON and Medical Records director are responsible for ensuring these processes are maintained. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On August 1, 2025, the Medical Records audited residents who have an order for going out on pass. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on providing/documenting unsupervised leave risk education, including the monitoring of the sign-in and out book for completeness and accuracy. On August 1, 2025, the Medical Records identified and audited the residents who smoke. All smoking assessments were audited for completeness and accuracy. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on smoking assessment completion at admission, re-admission, and quarterly. On August 1, 2025, the Medical Records audited residents with similar risk factors and confirmed timely neuro checks for the other fall case. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on following care plans and completing neuro checks after falls. What measures will be put in place or what systemic changes will the facility make to ensure that the deficient practice does not recur: To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, to initiate post-fall neuro checks in accordance with the facility's policy. The RN supervisor or designee now reviews all changes of condition daily to ensure neuro checks are initiated and documented. The DON and Medical Records Director are responsible for ensuring these processes are maintained. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. To ensure sustained compliance, the Medical Records conducts daily audits of the residents with an out-on-pass orders. The RN Supervisor or designee will monitor the completeness and accuracy of the signing-in and out book. Any omissions are reported immediately to the DON for corrective action and follow-up re-education. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews the out-of-the-facility education and monitoring of the sign-in and out book for completeness and accuracy. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. To ensure sustained compliance, the Medical Records completes a weekly review of smoking safety assessments for all identified smokers, ensuring they are complete, accurate, current, and incorporated into the care plan. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews the smoking assessments for completeness, accuracy, currency, and incorporation into the care plan. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. To ensure sustained compliance, the Medical Records conducts daily audits of all new falls to verify neuro checks and resident education are documented. Any omissions are reported immediately to the DON for corrective actions and follow-up re-education. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews care plan compliance quarterly to confirm interventions for falls. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. Compliance will be submitted to the QA committee monthly (Aug-Sep-Oct) or until substantial compliance is maintained. The Administrator will ensure compliance.
Failure to Report and Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to follow its policy and federal regulations regarding the reporting and investigation of alleged abuse when an incident occurred involving two residents. One resident alleged that another resident hit him on the right cheek, and in response, he hit back. The incident was witnessed by staff, and the involved residents were both found to be cognitively intact and able to make decisions. Documentation in the medical record described the event as an accidental graze to the cheek, with no injury noted, and the responsible party and physician were notified. However, staff interviews revealed that the incident was described as an altercation and considered by the charge nurse to be abuse, which should have triggered immediate reporting and a thorough investigation as per facility policy and federal requirements. Despite these requirements, the facility did not report the alleged abuse to the appropriate authorities, including the State Survey Agency and law enforcement, nor did it conduct a thorough investigation as required. The Director of Nursing confirmed that the incident should have been reported and investigated according to policy. This failure to report and investigate the alleged resident-to-resident physical altercation had the potential to leave the involved residents and others at risk of unaddressed abuse.
Plan Of Correction
What corrective action will be accomplished for those residents found to have been affected by the same deficient practice: On 6/12/25, after Administrator and DON were notified of the alleged abuse incident, immediate review of the incident was conducted. Upon review of 5/28/25 incident residents 1 and 2 were separated, monitored, and provided protective measures. Both resident 1 and 2 were assessed by the charge nurse, with no injuries identified. The physician, and responsible parties were notified of the incident. Resident 1 remains in the facility without any physical or psychological distress. On 6/12/25, the Administrator, DON, RN Supervisor, and charge nurse completed rounds and reviewed facility charts and current residents to determine if any other residents had been affected by the same deficient practice. No other residents were identified to have been affected. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken: A comprehensive audit of current residents' records was conducted by the Medical Records Director (MRD), DON, and Administrator on 6/12/25 to assess for any unreported or delayed reports of alleged abuse. No additional incidents of unreported allegations were identified. What measures will be put in place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 6/13/25, 6/26/25, 7/1/25, and 7/2/25, the DON initiated facility-wide in-service training for staff on the facility's Abuse Prevention Policy and Reporting Procedures, in accordance with federal and state regulations. The training emphasized the following: - All allegations or suspicions of abuse must be reported immediately to the Administrator (Abuse Coordinator), DON, and appropriate state agencies. - Immediate protection of the resident involved is mandatory while the investigation is ongoing. - Documentation of the incident, notification of responsible parties, and reporting to regulatory agencies must be completed promptly. - Staff understanding of the difference between suspicion of abuse and confirmed abuse, reinforcing the obligation to report suspected abuse without delay. - The Abuse Policy has been updated to include a mandatory reporting checklist to assist staff in ensuring compliance. - The Abuse Coordinator (Administrator) will review all incident reports weekly for compliance with reporting protocols. How the facility will monitor its performance to ensure solutions are sustained: The Medical Records Director will conduct weekly audits of incident reports for 3 months starting the month of June to September 2025 to verify timely reporting and documentation of suspected abuse. Results of the audits and any identified deficiencies will be presented to the monthly QA Committee for review and further action. Quarterly QA meetings will continue to review trends, audit findings, and provide recommendations for ongoing compliance for a minimum of two quarters or until compliance is fully sustained. The Administrator (Abuse Coordinator) and DON will provide ongoing oversight to ensure that all reporting requirements remain in full compliance with regulations.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate an alleged resident-to-resident physical altercation involving two residents. One resident alleged that another resident hit him on the right cheek, and in response, he hit back. Medical record reviews indicated that both residents were competent and cognitively intact at the time of the incident. Documentation from a change in condition note described the event as an accidental graze by one resident's hand, but staff interviews revealed conflicting accounts, with one CNA stating that the incident was reported as a hit and a retaliatory action. Despite these reports, there was no evidence that the facility conducted a thorough investigation into the incident. Interviews with staff present during the incident, including CNAs and LVNs, confirmed that the event was known and reported to nursing leadership. However, the Director of Nursing (DON) was unable to provide documentation or evidence of an investigation, such as interviews with involved staff or a formal review of the incident. The facility's policy required all allegations of abuse to be thoroughly investigated and reported, but this process was not followed in this case, resulting in a deficiency for failure to investigate and document the alleged abuse.
Plan Of Correction
What corrective action will be accomplished for those residents found to have been affected by the same deficient practice: On 6/25/25 upon notification of the alleged violation, the facility immediately initiated an investigation following the facility's Abuse Policy and Investigation Protocol. The involved resident (Resident 1) was assessed with no injuries noted, and protective measures were implemented during the immediate period of the alleged incident. The responsible parties (resident 1 is self-responsible, and responsible party for resident 2) were notified. The alleged perpetrator (resident 2) was discharged to a different facility on 6/17/25. On 6/25/26 and 6/26/25, the Administrator, DON, Medical Records Director, and Social Services reviewed current residents to ensure no other unresolved allegations were pending investigation. No other residents were identified as affected. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken: A review of the incident/accident logs, grievance logs, and nursing notes was conducted on 6/25/25 by the Administrator (Abuse Coordinator), DON, Medical Records Director, and Social Services to ensure that any previous allegations had been fully investigated, resolved, and documented appropriately. No additional concerns requiring investigation were identified. What measures will be put in place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 6/13/25, 6/26/25, 7/1/25, and 7/2/25, the DON conducted in-service training to staff on the facility's Abuse Prevention, Reporting, and Investigation policies, emphasizing: - All allegations of abuse must be reported immediately. - Prompt initiation of investigations upon receiving allegations. - Documentation of each step of the investigation process. - Implementation of protective measures during investigations. - Timely reporting of findings and corrective actions taken. Abuse Binders were placed in each nursing station with an investigation checklist to guide staff with proper documentation and timely follow-up. The Administrator (Abuse Coordinator) will review all incident reports weekly to confirm that any allegations are promptly investigated and resolved according to policy. How the facility will monitor its performance to ensure solutions are sustained: The Administrator (Abuse Coordinator), DON, and Medical Records Director will audit all investigation files weekly for the months of June to September 2025 to ensure allegations are investigated promptly and thoroughly, with documentation completed accurately. Results will be reviewed during monthly QA meetings, and trends or gaps will be addressed immediately. Quarterly reviews will continue thereafter to ensure continued compliance with regulations. The Administrator and Medical Records Director will oversee ongoing compliance, ensuring all allegations are investigated and resolved promptly. What measures will be put in place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 6/13/25, 6/26/25, 7/1/25, and 7/2/25, the DON conducted in-service training to staff on the facility's Abuse Prevention, Reporting, and Investigation policies, emphasizing: - All allegations of abuse must be reported immediately. - Prompt initiation of investigations upon receiving allegations. - Documentation of each step of the investigation process. - Implementation of protective measures during investigations. - Timely reporting of findings and corrective actions taken. Abuse Binders were placed in each nursing station with an investigation checklist to guide staff with proper documentation and timely follow-up. The Administrator (Abuse Coordinator) will review all incident reports weekly to confirm that any allegations are promptly investigated and resolved according to policy. How the facility will monitor its performance to ensure solutions are sustained: The Administrator (Abuse Coordinator), DON, and Medical Records Director will audit all investigation files weekly for the months of June to September 2025 to ensure allegations are investigated promptly and thoroughly, with documentation completed accurately. Results will be reviewed during monthly QA meetings, and trends or gaps will be addressed immediately. Quarterly reviews will continue thereafter to ensure continued compliance with regulations. The Administrator and Medical Records Director will oversee ongoing compliance, ensuring all allegations are investigated and resolved promptly.
Failure to Develop Comprehensive Care Plans After Resident Altercation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents following an incident in which one resident, who was confused, accidentally grazed another resident's right cheek while being moved by staff. The care plans did not reflect the individual care needs of either resident in relation to this incident, as required by federal regulations. Specifically, there was no care plan initiated on the day of the incident to address the event for either resident. Medical record reviews showed that both residents were competent and able to make decisions at the time of the incident. One resident had a BIMS score indicating cognitive intactness, and both had recent admissions or readmissions to the facility. Despite the incident being documented in the change in condition notes, the care plans for both residents did not include any problems or interventions related to the altercation. During an interview and concurrent medical record review with the DON, it was confirmed that the care plan problems related to the incident were missed for both residents. The DON acknowledged that the care plan for one resident was only completed after the surveyor's inquiry, which was not timely in relation to the date of the incident.
Plan Of Correction
What corrective action will be accomplished for those residents found to have been affected by the same deficient practice: On 6/13/25, the IDT (Interdisciplinary Team), including the Administrator, DON, MDS Coordinator, Social Services, and Dietary Manager, reviewed and updated the care plan of the identified resident to ensure it was comprehensive, addressing all assessed needs, goals, and interventions, including psychosocial, medical, and functional needs. The resident and responsible party were included in the care plan discussion, and documentation was completed in the medical record. On 6/13/25, the DON and MDS Coordinator reviewed other residents' active care plans for gaps or incomplete documentation. No other residents were found to have been affected by incomplete or non-comprehensive care plans. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken: A facility-wide audit of all current residents' care plans was initiated on 6/13/2025 by the Medical Records Director, MDS Coordinator, and reviewed by the DON to ensure all plans reflected residents' current status, needs, goals, and preferences. Any identified discrepancies were corrected immediately, with the care plan updated, and responsible parties notified as appropriate. No additional concerns were identified. What measures will be put in place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 6/13/25, 6/26/25, 7/1/25, and 7/2/25, an in-service training was conducted by the DON for licensed nurses and IDT members on the requirements for developing and implementing a comprehensive care plan per federal and state regulations. Training emphasized: - Care plans must address identified needs from resident assessments. - Care plans must include measurable goals, specific interventions, and timelines. - Involvement of residents and/or responsible parties in care-plan development. - Timely updates to care plans when changes in condition occur. The MDS Coordinator will conduct care plan audits to ensure completeness, resident-specific interventions, and timely updates. The IDT will conduct care plan reviews in weekly clinical meetings and quarterly care plan meetings with resident/family participation. How the facility will monitor its performance to ensure solutions are sustained: The DON and MDS Coordinator will conduct random audits of 5 resident care plans weekly for June to September 2025 to ensure compliance with comprehensive care plan requirements. Findings will be presented at the monthly QA meetings for review, trend monitoring, and corrective action planning if needed. Audits will continue quarterly thereafter to ensure ongoing compliance. The Administrator and DON will provide oversight to ensure care plans remain current, complete, and compliant with regulations.
Failure to Document Physician Basis for Resident Discharge
Penalty
Summary
The facility failed to ensure that the discharge process was properly followed for a resident, as required by its own policies and procedures. Specifically, the closed medical record for the resident did not contain documentation from the attending physician indicating the basis for the resident's discharge. The facility's policy states that the attending physician must document the reason for transfer or discharge in the clinical record, particularly if the discharge is due to the resident's welfare or improvement in health. However, a review of the resident's medical record revealed that, prior to providing the resident with the Letter of Continued Determination (LCD), there was no physician documentation supporting the discharge decision. Further review of the resident's history showed that the resident was admitted, had a physician's order for discharge, and was later transferred to an acute care hospital. The History & Physical examination indicated ongoing need for in-patient therapy, and there was no indication that the resident was ready for discharge based on physician documentation. Interviews with the Social Services Director and the Administrator confirmed the absence of required physician documentation correlating with the discharge planning and progress notes.
Failure to Obtain Orders and Consent for Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless needed for medical treatment. Specifically, the facility did not obtain a physician's order for the application of a soft mitten restraint on a resident's left hand. Additionally, the facility did not conduct the necessary assessments prior to applying the restraint, nor did it obtain informed consent from the resident or their representative. The resident involved had a medical history of hemiplegia and hemiparesis following a cerebral infarction, affecting the right dominant side, and aphasia. The resident was assessed as having severely impaired cognitive skills for daily decision-making and was not competent to enter into contracts. Despite these conditions, the facility did not have a care plan in place to address the use of restraints, nor did it monitor the resident for the use of the restraint as required by the facility's policies and procedures. Observations on two separate occasions confirmed that the resident was wearing a soft mitten restraint without the necessary documentation or oversight. Interviews with facility staff, including the Director of Staff Development (DSD), confirmed the lack of a physician's order, assessments, informed consent, monitoring, and care plan for the restraint. The DSD acknowledged that the mitten was considered a restraint and should have been documented accordingly. The facility's failure to adhere to its policies and procedures regarding restraint use had the potential to negatively affect the resident's physical mobility and psychosocial well-being.
Deficiencies in Oxygen and Medication Management
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment. For the first resident, the facility did not assess the need for supplemental oxygen or obtain a physician's order for its use, as required by the facility's policies and procedures. The resident experienced a change in condition with abnormal lung sounds and a drop in oxygen saturation, yet there was no documented evidence of monitoring or a physician's order for the increased oxygen administered. Additionally, the facility did not follow up with pharmacy services to ensure the timely delivery of breathing treatment medications, resulting in missed doses. The second resident's care was compromised by the facility's failure to maintain the humidifier on the oxygen concentrator. The humidifier was found to be unlabeled, undated, and empty, which could lead to discomfort due to dry air. The facility's policy required daily checks and refills of humidifiers, but this was not adhered to, as observed during the survey. Interviews with facility staff, including LVNs and the DON, revealed a lack of communication and follow-up regarding medication delivery and changes in residents' conditions. The staff acknowledged the deficiencies, including the absence of physician notification and pharmacy follow-up for the first resident's medication, and the failure to maintain the second resident's humidifier as per policy.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained the highest practicable physical well-being. Specifically, the facility did not notify the physician in a timely manner when the resident experienced a change in condition regarding the right leg. The facility's policy requires prompt notification of the physician and resident representative when there is a change in the resident's condition. However, this protocol was not followed, as evidenced by the lack of documentation and communication regarding the resident's leg condition. The resident, who was competent and had intact cognitive function, had a care plan addressing non-healing bilateral lower extremity cellulitis and risk for skin breakdown. Despite a physician's order for daily application of mupirocin ointment, the resident's right leg was observed to be purplish, cold, and with blisters, indicating a lack of circulation. The LVN who noticed these changes did not follow up on notifying the physician due to being busy and not knowing how to document the change. The RN and interim DON confirmed the absence of documentation and notification, acknowledging the oversight in communication and documentation of the resident's condition change.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services to treat and prevent pressure injuries for a resident, identified as Resident 2. The resident, who was not competent and had impairments in both upper and lower extremities, was dependent on staff for bed mobility and toileting and was always incontinent. The facility did not follow the physician's orders for wound treatment, as observed when LVN 5 applied Medihoney instead of the prescribed Santyl ointment to the resident's elbow wounds. This discrepancy was acknowledged by LVN 5, who stated that Medihoney was used based on a wound consultant's recommendation when Santyl was unavailable, but without obtaining a physician's order for this substitution. Additionally, the facility failed to develop a care plan to address the resident's Stage 3 pressure injuries on the right lower back, sacrum, and lumbosacral spine. Although a care plan was initiated to address the resident's risk for skin breakdown due to incontinence and fragile skin, it did not include specific interventions for the existing Stage 3 pressure injuries. This omission was confirmed by LVN 5 during an interview, who verified that no care plan was initiated for these specific pressure injuries. The interim DON and the Administrator were informed of these findings and acknowledged the deficiencies. The interim DON stated that nurses are expected to follow physician's orders and clarify them as needed, and that each pressure injury should have a treatment order and a written plan of care. However, the facility's failure to adhere to these protocols resulted in the resident not receiving the appropriate care and services to promote healing of the pressure ulcers.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that five residents were free from unnecessary psychotropic medications, as evidenced by the lack of non-pharmacological interventions and proper monitoring. Resident 745 was prescribed multiple psychotropic medications, including quetiapine, Ativan, duloxetine, and divalproex sodium, without evidence of non-pharmacological interventions. Additionally, there was no monitoring for side effects or behavior for Ativan use, and the resident was not reassessed for the as-needed use of quetiapine beyond 14 days. Resident 84 was prescribed Xanax and Remeron without proper reassessment or informed consent. The facility did not limit the PRN order for Xanax to 14 days, and there was no informed consent obtained prior to its administration. Furthermore, there was no evidence of non-pharmacological interventions for the use of Remeron. The Director of Nursing (DON) acknowledged these deficiencies during an interview. Residents 5 and 19 were also affected by the facility's failure to limit PRN orders for psychotropic medications to 14 days. Both residents were prescribed lorazepam without documented reasons for extending the medication beyond the 14-day limit. Additionally, Resident 64's informed consent for psychotropic medications was improperly obtained, as the consent was signed by the resident who was deemed not competent. The DON and other staff members verified these findings, indicating a systemic issue with the facility's management of psychotropic medications.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement effective infection control practices, as evidenced by the absence of monthly Infection Prevention and Control Surveillance logs for several months in 2024. The Infection Preventionist (IP) confirmed the lack of documentation for July, September, and December 2024, attributing the September lapse to the departure of the previous IP. Additionally, the surveillance logs from August to November 2024 did not include whether residents met Loeb's criteria for true infection, instead using McGeers criteria, which was not in line with the facility's stated practices. The facility's Infection Prevention and Control Quality Assurance (QA) Reports for October and November 2024 were found to be inaccurate, with discrepancies between the QA Reports and the Infection Surveillance Monthly Reports. The IP, who prepared these reports, was unable to explain the inconsistencies. Furthermore, the IP did not maintain a surveillance log to track residents who met or did not meet Loeb's criteria, and only included residents prescribed antibiotics in the infection surveillance report, omitting those with signs and symptoms of infection who were not prescribed antibiotics. Additional deficiencies were observed in staff practices, including failure to perform hand hygiene after glove removal during medication administration and wound care, and improper handling of a Foley catheter bag. Enhanced Barrier Precautions (EBP) were not implemented correctly, as evidenced by the absence of EBP signage and PPE carts for residents requiring such precautions. The IP admitted to insufficient training and lack of knowledge about the EBP protocols, further contributing to the facility's failure to control the transmission of infections effectively.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that three residents were safe to self-administer medications found at their bedside. Resident 394 was observed with dorzolamide eyedrops at her bedside, which she administered herself without an assessment or a physician's order authorizing self-administration. Despite having the capacity to make decisions, Resident 394's medical records did not reflect any orders for self-administration of the medication, and she had previously indicated she did not want to self-administer her medications. Resident 74 was found with a gabapentin capsule in a medication cup on her nightstand, which she stated was left by the charge nurse for her to take later. Although Resident 74 was competent and able to make decisions, there was no assessment or physician's order for her to self-administer the gabapentin. The nurse confirmed that Resident 74 had not been assessed for safe self-administration, and no such order existed in her medical records. Resident 24 had Vicks VapoRub ointment on her bedside table, which she applied herself. Her medical records did not contain a physician's order for the ointment or for self-administration. The nurse verified the absence of such an order and acknowledged the need to notify the physician. These oversights in assessments and documentation posed a risk of inaccurate medication administration and potential adverse reactions.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach and accessible for several residents, which could lead to delays in care and negatively impact residents' psychosocial well-being. Observations and interviews revealed that multiple residents, including those requiring substantial assistance with bed mobility, were unable to reach their call lights. For instance, Resident 9 was observed yelling for help as the call light was clipped out of reach, and Resident 38 reported frequently needing to ask her roommate to press the call light for her. These issues were confirmed by staff members during interviews. Additionally, during a Resident Council meeting, several residents reported similar issues with call light accessibility, indicating a pattern of neglect in ensuring call lights were within reach. Resident 5 mentioned having to yell for help, while Resident 35 noted that CNAs often forgot to place the call light within reach after providing care. Resident 48 was observed with the call light hanging on a wheelchair, away from the bed, despite being able to use his upper extremities. These findings highlight a systemic issue in the facility's adherence to its policy on call light accessibility.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately address concerns raised by residents during Resident Council meetings on three separate occasions. On 7/11/24, a resident reported not receiving pain medication on time, but there was no documentation showing that the nursing department addressed this issue. On 9/12/24, residents expressed dissatisfaction with medications not being ordered on time and a lack of snacks, yet the response from the nursing department was illegible, and there was no documentation indicating that the dietary department addressed the snack concern. On 10/10/24, residents reported that CNAs sometimes spoke to them in a childish tone, but this concern was not documented as being addressed by the nursing department. Interviews with facility staff, including the Activities Director, DON, DSD, and CDM, revealed that these concerns were not communicated effectively to the relevant departments. The DON and DSD were unaware of the issues raised in the meetings, and the CDM was not informed about the dietary concerns. The Activities Staff relied on the Resident Council Departmental Response Form to document and communicate these concerns, but without proper documentation and follow-up, the facility failed to take appropriate administrative actions to resolve the issues raised by the residents.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of certain residents. Resident 9 was observed watching a television program in a language she did not understand, as her preferred language was not available. Despite being awake and in bed, Resident 9 did not have access to a television in her preferred language, which was confirmed by CNA 7. This lack of access to preferred language programming was not addressed, leaving Resident 9 without appropriate activities that met her interests. Resident 22, who had limited English proficiency, was also affected by the facility's failure to provide activities in her preferred language. Although her care plan indicated a need for 1:1 enrichment programming and activities that accommodated her communication abilities, Resident 22 was observed watching her roommate's television in a language she did not understand. The Activities Director and Staff confirmed that Resident 22's activity participation records for January 2025 were blank, indicating a lack of engagement in activities that met her preferences. Additionally, the facility's activities department was responsible for supervising residents who smoked, which interfered with scheduled activities such as Bingo games. Residents 5 and 35 expressed concerns that their Bingo games were cut short to accommodate smoking supervision. The Activities Staff confirmed that the Bingo game was often interrupted or started late due to the need to supervise smoking residents, particularly on weekends. This disruption in scheduled activities did not align with the residents' preferences and contributed to dissatisfaction among the residents.
Failure to Update Liquid Consistency Order
Penalty
Summary
The facility failed to provide a resident with the prescribed liquid consistency diet as per the physician's order. During an initial tour, a cup of thin clear liquid was observed on the resident's bedside table, despite the resident's meal ticket indicating a thin liquid consistency order. A CNA confirmed the presence of the thin liquid and removed it, while also pointing out a pitcher labeled as nectar thickened liquid. The Speech Therapist later confirmed that the resident's liquid consistency order had been changed from nectar to thin liquid consistency. Further investigation revealed that the resident's care plan had not been updated to reflect the change in liquid consistency order from nectar to thin liquid, as per the physician's order dated 1/2/25. The Director of Nursing (DON) and the Administrator verified these findings. The resident, who had a severe cognitive impairment with a BIMS score of six, was at risk of aspiration due to a decline in swallowing, as noted in the care plan dated 11/21/24.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide necessary respiratory care for four residents, leading to deficiencies in their care. Resident 44's nasal cannula was not properly applied, as the nasal prongs were not inserted into the resident's nose, despite the oxygen being administered at two liters per minute. This was confirmed by LVN 1 during an observation, who then corrected the placement of the nasal cannula. Resident 44's medical records indicated a diagnosis of hypoxemia, necessitating continuous oxygen administration. Resident 97's oxygen cannula was found on the floor and not stored in a clean set-up bag, and there was no physician's order for oxygen administration. Additionally, a No Smoking/Oxygen in Use sign was not posted outside the resident's room, contrary to the facility's policy. These findings were verified by LVN 5 during an observation and interview. The absence of proper signage and storage practices for oxygen equipment was also noted for other residents using oxygen. For Resident 99, a nebulizer mask and canister were improperly stored inside a reusable shopping bag, rather than a clean set-up bag. This was confirmed by LVN 5 during an observation. Similarly, Resident 20's nebulizer mask and canister were found on a nightstand without proper storage, as verified by RN 1. The Central Supply Staff indicated that respiratory equipment should be changed weekly and as needed, and that licensed nurses have access to the necessary supplies to maintain proper storage and signage.
Inaccurate Monitoring of Dialysis Resident's Fluid Intake and Output
Penalty
Summary
The facility failed to accurately monitor the fluid intake and output for a resident receiving hemodialysis care, which could lead to life-threatening conditions related to fluid imbalance. The facility's policy required accurate documentation of intake and output when ordered by a physician or implemented by nursing staff. However, the medical records for the resident showed discrepancies in the documentation of fluid intake and output. The resident's medical records indicated an average daily fluid intake of 500 to 640 ml, with outputs recorded as three times daily. However, the Weekly Intake and Output Evaluation showed inconsistent data, with a 24-hour average intake of 1100 ml and varying outputs, which did not match the daily records. The nursing staff estimated the resident's fluid output based on the condition of incontinent briefs, and dietary intake was assumed based on the percentage of food consumed, rather than being accurately measured. The facility's documentation practices did not align with the physician's orders for fluid restriction, leading to inaccurate monitoring of the resident's fluid status. The discrepancies were verified by RN 2, who acknowledged that the intake and output were assumed rather than accurately monitored, highlighting a significant deficiency in the facility's care for the resident requiring dialysis.
Inadequate Training and Competency in Infection Control
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) and other nursing staff had the necessary competencies to provide safe and efficient care to residents. The IP was unable to identify the six moments of Enhanced Barrier Precautions (EBP) and failed to document meeting minutes for the Infection Control Committee. Additionally, the IP incorrectly identified Healthcare-Associated Infections (HAI) and Community-Acquired Infections (CAI), and misunderstood the definition of infection onset date. These deficiencies were compounded by the IP providing inaccurate information to a physician regarding a resident's antibiotic use. The facility's policies and procedures required the IP to lead infection prevention efforts and ensure staff competency. However, the IP reported insufficient training, having only received four days of training for the role. This lack of training contributed to the IP's inability to perform essential duties, such as correctly identifying infection types and documenting critical infection control meetings. The IP's lack of knowledge and training posed a risk to resident safety and infection control within the facility. Furthermore, the facility failed to provide adequate training on EBP to Certified Nursing Assistants (CNA) and Licensed Vocational Nurses (LVN). CNA 8 and LVN 6 were unable to correctly identify when to use EBP and had not received recent in-service training on the subject. This lack of training and competency among staff members increased the potential for improper infection control practices, further endangering resident safety.
Failure to Monitor Opioid Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring of a resident's drug regimen, specifically concerning the use of Norco, an opioid medication. The facility's policy and procedure (P&P) for pain management, dated October 2022, required staff and physicians to monitor for adverse effects of pain medications, including opioids. However, a review of the medical records for a resident, who had the capacity to make medical decisions, revealed no documentation of monitoring for side effects related to Norco, as per the facility's P&P. The resident had an order for Norco to be taken orally every four hours as needed for moderate to severe pain. During an interview, a registered nurse confirmed the absence of documentation for side effect monitoring. The Director of Nursing was informed and acknowledged these findings.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 23.33%. During a medication administration observation, three licensed nurses (LVNs) were found to have made errors. LVN 1, while administering medications to Resident 32, did not assess the resident's apical pulse and lung sounds before administering budesonide inhalation, and left residual Lasix in the medicine cup. This was contrary to the physician's orders which required monitoring of blood pressure, apical pulse, and lung sounds pre and post administration. LVN 2, during a medication administration for Resident 29, failed to administer Augmentin and ferrous sulfate with food, as required by the physician's orders and the medication's bubble pack instructions. This oversight was acknowledged by LVN 2, who noted the need for clarification of the order with the physician. LVN 3, while administering medications to Resident 745, did not administer tamsulosin, duloxetine, and quetiapine fumarate, despite these medications being signed as given on the Medication Administration Record (MAR). The resident was noted to be not competent and unable to enter into a contract, including an admission agreement. The Director of Nursing (DON) and Administrator verified and acknowledged these findings.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that Resident 745 was free from significant medication errors, as observed during a survey. The resident, who had been prescribed duloxetine for depression, quetiapine fumarate for manic disorder, and tamsulosin for symptoms of an enlarged prostate, did not receive these medications as required. On the day of the survey, LVN 3 did not administer the prescribed medications to Resident 745, despite having signed the Medication Administration Record (MAR) as if they had been given. Further investigation revealed that the medications were initially filled for a 14-day supply on December 19, 2024, with a refill request made on December 26, 2024, which was not fulfilled. The pharmacy's records indicated that the last doses were administered on January 2 and 3, 2025, and no further medications were available. The facility's Director of Nursing (DON) and Administrator confirmed these findings, acknowledging the lapse in medication administration for Resident 745.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, as evidenced by several observations of expired and improperly stored medications. During an inspection of Medication Cart C, expired Hydrogel impregnated gauze and Curad oil emulsion dressings were found, along with open and single-use wound dressings that were not discarded after use. Similar issues were noted with Medication Cart A, where a bottle of Active liquid Protein Concentrated nutrition was found sealed but expired, and another bottle was found open. Additionally, a Covid self-test with an extended expiration date was found in Medication Room A, and an unlabeled Amjevita auto injection was found in Medication Room B. The facility also failed to ensure medications were not left unattended in residents' rooms. A bag containing wound dressings and ointments was found on a resident's nightstand, and the resident was unaware of its presence. Similarly, medication cups containing white pasty cream were left on the nightstands of two other residents, with no licensed staff present. These residents were either unaware of the medication or confirmed it was for their use, but the nursing staff should not have left the medications unattended. Furthermore, the facility did not maintain accurate labeling and secure storage of medications for another resident, as a white cream was found on the bedside stand without a corresponding physician's order. A Vitamin A&D packet was also left on a resident's bedside table, despite physician orders for its application. These failures in medication management and storage had the potential to negatively impact residents' well-being and lead to medication errors, as acknowledged by the Director of Nursing and other staff members.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by several observations during a survey. Two coffee pots were found stored wet, contrary to the USDA Food Code 2022, which requires equipment and utensils to be air-dried before storage to prevent microorganism growth. Additionally, the kitchen equipment and utensils were not maintained in a sanitary condition. A white freezer was observed with brownish-black discoloration on its Styrofoam lining, and four small red bowls with dried food crumbs were stored in a clean dish storage area. The facility's Certified Dietary Manager (CDM) confirmed these observations and acknowledged the need for proper cleaning. Further deficiencies were noted in the maintenance of the ice machine and the food preparation sink. The ice machine's inside lining was peeling and had a sticky brown discoloration, which the Maintenance Director confirmed was not a cleanable surface. Additionally, the food preparation sink lacked a backflow prevention system, as required by the USDA Food Code 2022, to prevent contamination from the sewage system. The Maintenance Director was unable to demonstrate the presence of a backflow prevention system, confirming the deficiency.
Deficiency in Hospice Care Documentation and Scheduling
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services was provided with the necessary care and services. Specifically, the facility did not maintain an accurate hospice visit calendar in the resident's medical record, nor did it ensure that hospice staff visits were documented accurately. The hospice provider's plan of care required a skilled nurse to visit weekly, a hospice aide to visit twice weekly, and a social worker to visit monthly. However, the facility's records did not include a calendar for January 2025, and the December 2024 hospice calendar lacked proper documentation of visits, including the designation of the visiting staff. Interviews with facility staff, including an LVN and the DON, confirmed these deficiencies. The LVN was unable to verify the hospice staff's visit schedule or confirm if the plan of care was followed. The DON acknowledged the lack of documentation and verification of hospice visits. These failures posed a risk for delayed communication and provision of hospice care between the hospice provider and the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program effectively, as evidenced by the inability of the Infection Preventionist (IP) to provide documentation that physicians were notified about residents who were prescribed antibiotics without meeting Loeb's Criteria. This oversight was identified during an interview and concurrent record review with the IP, where it was revealed that there was no documentation to show that the physicians were informed about the inappropriate antibiotic prescriptions. The Director of Nursing (DON) acknowledged these findings and confirmed that the IP should have notified the physicians about the residents who were prescribed antibiotics without meeting the necessary criteria. The report highlights that antibiotics are frequently prescribed in nursing homes, with a significant portion being prescribed incorrectly. The facility's policy, revised in December 2016, mandates that antibiotics should be prescribed and administered under the guidance of the antibiotic stewardship program. However, the failure to notify physicians about residents who did not meet Loeb's Criteria for antibiotic use indicates a lapse in the program's implementation. This deficiency has the potential to lead to inaccurate identification of true infections and may prevent residents from receiving appropriate treatment and care.
Facility Fails to Maintain Homelike Environment Due to Chipped Paint
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for a resident, as evidenced by chipped paint on the wall by the resident's head of bed. During an initial tour, the chipped paint was observed, and the Maintenance Director, upon touching the chipped paint, stated that they had not seen it before and acknowledged the findings. A Certified Nursing Assistant (CNA) confirmed that the chipped paint had been present for a week but admitted to forgetting to report it, as their focus was on the resident. The Administrator and Director of Nursing (DON) were informed and acknowledged the findings.
Failure to Notify Resident's Representative of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident's representative of their right to a bed hold policy upon the resident's transfer to an acute care hospital. This deficiency was identified during a review of the facility's policies and procedures, which require that residents and their representatives be informed in writing of the bed hold policies both in advance of any transfer and at the time of transfer. In the case of Resident 44, who was not competent to enter into a contract, there was no documented evidence that the resident's representative was notified of the bed hold provision when the resident was transferred to the hospital. Interviews with facility staff, including an LVN and the Admissions Coordinator, confirmed the absence of documentation regarding the bed hold notification for Resident 44. The LVN acknowledged that the responsible party should have been informed of the bed hold to ensure awareness of the resident's ability to return to the facility within seven days. The Admissions Coordinator also verified the lack of bed hold notification documentation in the resident's medical record. The Director of Nursing was informed of these findings and acknowledged the deficiency.
Latest citations in California
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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