Hollywood Premier Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 5401 Fountain Ave., Los Angeles, California 90029
- CMS Provider Number
- 056489
- Inspections on file
- 66
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 45 (1 serious)
Citation history
Health deficiencies cited at Hollywood Premier Healthcare Center during CMS and state inspections, most recent first.
Two residents with significant ADL needs were found living in a room with brown stains and food particles on the floor, and an open urinal containing urine hanging from a bed rail, indicating missed CNA and housekeeping duties. One roommate reported that housekeeping had not cleaned the floor since the previous day. A family member also reported seeing roaches in the lobby on two occasions, and surveyors observed food droppings on floors in resident rooms, creating unsanitary conditions that could contribute to pest activity, despite facility expectations for routine housekeeping rounds and consistent cleaning around meal and snack times.
A resident with dementia, bipolar disorder, impaired cognition, and a documented history of exit-seeking behaviors was not accurately identified as an elopement risk on the facility’s Wander/Elopement Risk Evaluation, which failed to list dementia or other decision-making impairments and concluded there was no elopement risk. Despite care plan directives to assess elopement risk and facility policies requiring identification of residents at risk for unsafe wandering or elopement, staff, including an LVN, did not recognize or document the resident’s dementia diagnosis on the risk tool. Subsequently, the resident, who used a wheelchair independently and had been awake and moving in the hallway overnight, self-propelled past a nearby housekeeper and exited through an unlocked front door, and was later discovered missing during rounds, prompting a facility search and police notification.
A resident with severe cognitive impairment and documented lack of decision-making capacity was maintained on Depakote 500 mg TID for mood and behavioral management, and an informed consent form for this psychotropic medication was signed by the resident rather than a legally authorized representative. Nursing notes indicated that risks, benefits, side effects, and FDA black box warnings were discussed and that the resident verbalized understanding, but later observation showed the resident was confused and unable to explain their medications. The social services director confirmed the resident lacked capacity and that no responsible party or bioethics committee had been involved, while an RN supervisor and the psychiatrist both acknowledged it was a deficiency to have the resident, who lacked capacity, sign the consent, contrary to facility policy requiring consent from a legally authorized representative.
Two residents were involved in a physical altercation when a cognitively impaired, elopement‑risk resident with mood and psychotic disorders, who had been ordered for 1:1 supervision, entered another resident’s room without being accompanied by staff. The second resident, who had schizophrenia but intact cognition and was independent in ADLs, pushed the first resident out of the room and they grabbed each other. The DON later confirmed that the 1:1 supervision ordered in a psychiatric note was not reflected in the care plan and was not being provided at the time of the incident, despite facility policies requiring adequate supervision, comprehensive care planning, and targeted interventions for residents at risk of unsafe wandering.
A resident with dementia and severely impaired cognition, who required assistance or supervision with multiple ADLs, experienced increased confusion and disorientation and attempted to leave the facility, stating that his daughter needed him. An SBAR form documented this behavioral change and elopement attempt, but there was no documentation that any family member, guardian, or other responsible representative was notified. An LVN acknowledged that staff did not notify the family, and the DON stated that family notification and documentation are expected following such behavioral changes, consistent with facility policy requiring prompt notification of the resident representative after significant changes in medical or mental status.
A resident with severe cognitive impairment experienced a seizure, elevated heart rate, and low oxygen saturation. Nursing staff provided oxygen and left a message with the physician's answering service, but there was no documentation of a physician response or new orders. Facility policy requiring escalation to the medical director if the physician did not respond was not followed.
A resident with diabetes and severe cognitive impairment did not have their blood sugar monitored after being unable to eat for over six hours due to a dislodged nasogastric tube. Nursing staff did not perform a blood glucose check during this period, despite facility policy and the resident's care plan requiring monitoring in such situations.
A resident with multiple medical conditions and severe cognitive impairment did not receive a physician-ordered comprehensive metabolic panel (CMP) because staff failed to obtain the required blood sample and did not document the omission. Facility staff confirmed the test was not performed and no explanation was recorded, resulting in the absence of necessary laboratory information for the resident's care.
A resident with severe cognitive impairment and total dependence on staff was sexually abused by another resident who had a known history of inappropriate sexual behavior, including public masturbation and disrobing. Despite repeated documentation of these behaviors, the facility did not implement effective monitoring or interventions, nor did it conduct an interdisciplinary team meeting to address the risks. The incident was discovered by a CNA, and the abused resident was unable to communicate about the event.
The facility did not implement its Plan of Correction requiring a third-party consultant to provide staff training and monitoring on resident-to-resident sexual abuse prevention. Despite internal in-service sessions, no staff received the mandated external training, and none of the outlined monitoring or reporting activities were initiated as required by the facility's abuse prevention program.
A resident with a documented history of inappropriate sexual behavior, including public masturbation and disrobing, was not adequately monitored or supervised, leading to the sexual abuse of a nonverbal, fully dependent resident. Despite repeated incidents and clear documentation, staff did not convene an IDT meeting to address the behavior or implement effective interventions.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the plan was not prepared, reviewed, and revised by a team of health professionals as required.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment lacked proper hazard controls and sufficient monitoring, increasing the risk of accidents.
Two residents requiring special eating equipment did not receive the correct devices or proper assistance during meals. One resident with limited arm mobility had a plate guard positioned incorrectly, causing food to spill, while another resident was given a regular plate with a plate guard instead of the ordered divided plate. Staff confirmed the devices were not used as specified in care plans and physician orders.
Surveyors found that food items in a storage area were not properly labeled or dated, including meat patties, chopped meat, and other frozen products. The Dietary Supervisor confirmed that facility policy requires all opened and partially used foods to be labeled and dated before storage, but several items were missing this information or had unreadable labels.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with schizophrenia and bipolar disorder, who lacked decision-making capacity, was administered risperidone, quetiapine, and valproic acid without proper informed consent from a representative. Facility records showed only verbal consent from the resident, despite documentation of cognitive impairment, and interviews with the DON and Medical Director confirmed that required consent procedures were not followed.
A resident with severe cognitive impairment and multiple medical conditions was admitted without the facility providing advanced directive information or documentation to the responsible party, despite policy requiring this upon admission. Interviews confirmed that neither inquiry nor information about advanced directives was given to the resident's representative.
A resident with significant medical needs, including total dependence for care and a surgical wound, was found lying on a mattress placed directly on the floor without a bed frame or bedrails, despite the care plan specifying a high-low bed. Staff reported that this arrangement was unsafe and hindered proper care, and facility leadership confirmed that alternative interventions were available and that required staff training had not been provided.
A resident with multiple mobility and neurological conditions was identified as being at risk for falls, yet the facility did not develop or implement a care plan to address the resident's repeated practice of raising the bed to its highest position. Despite staff awareness of the resident's non-compliance with safety protocols and observations of the call light being out of reach, the care plan was not updated to address these specific risks.
A resident with diabetes, acute kidney failure, and severe cognitive impairment did not have a post void residual (PVR) measurement documented every six hours as ordered by the physician. Nursing staff failed to record the 6 AM PVR, contrary to both physician orders and facility policy, resulting in incomplete monitoring and documentation of the resident's treatment.
A resident with chronic pain and dementia did not receive a scheduled dose of hydrocodone-acetaminophen because the medication was not available and the nurse did not access the emergency kit as per facility protocol. The resident reported ongoing issues with medication availability, and documentation confirmed the missed dose.
Surveyors found that several medication bubble packs in use for three residents with complex medical and cognitive needs were missing expiration dates, contrary to facility policy and professional standards. During medication cart inspections, LVNs confirmed the absence of expiration dates on bubble packs containing rivastigmine, trihexyphenidyl, and lurasidone.
A resident with significant mobility and coordination impairments, who was dependent on staff for most activities of daily living, did not have their call light within reach while in bed. Observation confirmed the call light was inaccessible, and both a CNA and the DON acknowledged the resident would be unable to call for assistance. Facility policy required call lights to be accessible, but this was not followed in this instance.
Surveyors found that a room contained five beds, exceeding the maximum allowed occupancy of four. Although only four residents were present and both residents and staff reported sufficient space for care and mobility, the room setup did not comply with regulatory requirements.
A resident with a history of mental health disorders exhibited escalating behavioral symptoms, including panic attacks and aggression, but the facility did not update the care plan or conduct an IDT meeting after significant incidents. This lack of intervention led to the resident physically assaulting another resident, resulting in injury and hospitalization.
A resident was prescribed Duloxetine HCL, a psychotropic medication, without a signed informed consent. Despite being alert and oriented, the resident's chart lacked documentation of informed consent, which is required for psychotropic drugs. Facility staff acknowledged the absence of a specific informed consent policy and attributed the responsibility to the doctor, while the RN supervisor did not document obtaining consent.
A facility failed to readmit a resident after hospitalization, despite the resident being medically stable. The resident, with a history of bipolar and schizoaffective disorders, was initially transferred to a hospital under a 5150 hold. The facility cited safety concerns and an inability to meet care needs as reasons for not allowing the resident's return, despite the hospital's clearance and attempts by the social worker to facilitate the return.
The facility failed to maintain a clean and sanitary environment in two shower rooms, where soiled items and hair were found on the floor and drain. Housekeeping staff confirmed the rooms were not clean, and the DON stated they should be cleaned after each use, as per facility policy.
A resident with severe cognitive impairment and total dependence on staff was left unsupervised when a CNA was found asleep in the resident's room. This lack of supervision posed a risk of accidents, as confirmed by other staff members and the facility's policy on resident safety and supervision.
A resident on a renal diet expressed dislike for mocha mix, a non-dairy creamer, which was repeatedly included on their meal tray despite their preferences being documented. The Dietary Supervisor failed to consult with the Registered Dietitian for a substitute, leading to a breach in the facility's policy on addressing conflicts between nutritional needs and resident preferences.
A facility failed to ensure a safe and orderly discharge for a resident with multiple health conditions by not involving them or their family in the discharge planning process. The facility did not develop or review a post-discharge plan with the resident or their family, and there was no documentation of follow-up regarding the discharge plan. The family member was not offered tours of potential facilities and was not informed about the appeal process for discharge, contrary to the facility's policy.
A resident reported $40 missing, but the LTC facility failed to properly investigate the claim. Despite the resident being cognitively intact and the loss reported to an LVN, the required Theft and Loss Form was not completed, nor was the incident reported to the SSD. The facility's policy mandates prompt investigation of such reports, which was not followed.
A resident with congestive heart failure was administered Metoprolol Tartrate and Hydralazine without blood pressure parameters, contrary to professional standards. The care plan noted a risk for fluctuating blood pressure but lacked specific limits for these medications. Interviews with staff highlighted the necessity of such parameters to prevent hypotension, which was not implemented, placing the resident at risk.
The facility failed to update the care plans for two residents, leading to potential inadequate care. One resident's care plan did not reflect the current physician orders for tube feeding, while another resident's care plan was not updated to reflect the correct antibiotic dosage. The Director of Nursing acknowledged the oversight, which could result in unmet needs and inadequate care.
The facility failed to maintain yearly staff competency and mandated abuse reporting training records for two CNAs, with missing documentation spanning several years. The DSD acknowledged the issue, attributing it to previous staff misplacing files, and is working on QAPI plans to address the deficiency.
A resident with schizophrenia did not receive necessary behavioral health services due to the discontinuation of prescribed Risperidone without consulting a physician, and missed psychology consultations. The resident's care plan was not revised quarterly, contrary to facility policies, leading to inadequate care.
A facility failed to securely store medications and properly label insulin, leading to potential risks. An LVN left medications, including a controlled substance, unattended, risking diversion and exposure. Additionally, insulin for a resident was improperly labeled with two dates, causing uncertainty about its expiration and safety.
The facility failed to properly store and handle food, as evidenced by an opened and undated package of cookies found in the pantry and a cook serving food without washing hands after rinsing a towel. These actions risked contamination and potential foodborne illnesses.
A LTC facility failed to implement proper infection control measures for six residents. An RNA used inappropriate cleaning agents on a cloth gait belt, and a resident's urinals were improperly stored in a trash can. Additionally, an LPN did not disinfect medication trays and cart countertops between resident room visits, increasing the risk of infection spread. These actions were contrary to the facility's infection control policies.
A resident's room in the facility had a damaged vinyl floor with a crack and chip, creating an uneven surface that posed a fall risk. The damage had been present for several months, and staff, including a CNA and the Director of Maintenance, were aware of the issue. Despite plans to repair the floor, no specific timeframe was provided, and the facility's policy on maintaining a safe and homelike environment was not upheld.
A resident was prescribed Diflucan for fungal pneumonitis, but the facility failed to include this medication in the resident's care plan. Despite the resident's cognitive intactness and need for assistance in daily activities, the care plan was not updated to reflect the physician's order, as confirmed by the DON. This oversight contradicts the facility's policy requiring comprehensive, person-centered care plans.
A resident with stage three and unstageable pressure ulcers was found to have an incorrectly set low air loss mattress (LALM) in a LTC facility. The LALM was set for a weight of 200 lbs, while the resident weighed 145 lbs, contrary to physician orders and care plan instructions. This discrepancy was acknowledged by the Treatment Nurse and the DON, highlighting a failure in monitoring and adherence to facility policies.
A resident in an LTC facility was at risk of receiving an incorrect dosage of docusate sodium liquid due to a physician order lacking clarity on the medication's strength and dose. The resident, who required full assistance for daily activities, was observed receiving a 25 mL dose without specified strength. Interviews with staff highlighted the importance of clarifying such orders to prevent potential health risks.
The facility failed to ensure Dietary staff had the necessary skills to use QT-40 test paper for sanitizer concentration, as observed when a Dietary Aide did not follow guidelines, potentially risking cross-contamination and foodborne illness for 88 residents. The temporary Dietary Supervisor was unsure of staff competencies, despite records showing evaluations were completed. The Director of Staff Development and DON indicated a lapse in proper education and evaluation.
The facility failed to maintain a sanitary environment, leading to a fly infestation around the waste disposal area. Open trash bins filled with food leftovers attracted flies, posing a risk for infection outbreaks. Despite regular pest control visits and recommendations to cover trash, the facility did not effectively implement these measures, resulting in the observed deficiency.
A facility was found to have a room with five beds, exceeding the regulatory limit of four residents per room. Despite staff stating there was enough space for care, the room's occupancy violated standards. The facility requested a waiver, claiming adequate space for resident safety and care.
A facility failed to ensure a resident was informed of the risks and benefits of psychoactive and hypnotic medications, violating their right to make an informed decision. The resident, with impaired cognition and multiple diagnoses, was taking medications like Zyprexa and Lorazepam without documented informed consent from a physician, as required by facility policy. The DON confirmed the lack of evidence for informed consent, leading to the deficiency.
A facility failed to initiate a care plan for Zyprexa, an antipsychotic medication, for a resident with schizophrenia, depression, and type 2 diabetes. Despite a physician's order for Zyprexa to manage aggressive behavior, no care plan was developed. The DON acknowledged the oversight, highlighting the need for measurable objectives to meet the resident's needs.
A facility failed to supervise residents in the smoking patio, leading to an altercation where a resident with severe cognitive impairment hit two other residents. Despite the facility's policy requiring supervision during smoking hours, staff were not present after the receptionist left, allowing the incident to occur.
Failure to Maintain Clean and Sanitary Resident Rooms and Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, clean, and comfortable environment in resident rooms and common areas, as required by its homelike environment policy. Surveyors observed that one resident room had brown stains and visible food particles on the floor, suggesting inadequate and untimely housekeeping that appeared to have been present beyond the current day. An open-lid plastic urinal containing yellow urine was hanging from the bed rail in the same room, despite the resident having left for dialysis earlier in the day. The facility’s DON stated that CNAs are supposed to empty urinals and not leave them with open lids on bed rails, and that residents should have a clean environment throughout the day. Resident 1, who had ESRD and hemiplegia and required extensive assistance with ADLs, and Resident 2, who had muscle weakness and required partial assistance with ADLs, were both affected by the unclean environment in their shared room. Resident 2 reported that housekeeping had not provided services that day and that the floor had not been cleaned since the previous day. A family member of Resident 1 alleged seeing roaches in the facility on two occasions, most recently in the lobby, and although no roaches were observed during the survey, surveyors noted food droppings on floors in resident rooms, creating unsanitary conditions that could contribute to pest activity. The DON confirmed that housekeeping staff are expected to make routine rounds and that meal and snack times require consistent cleaning to maintain sanitation, which was not evident in the observed conditions.
Failure to Accurately Assess Dementia-Related Elopement Risk Leading to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a diagnosis of dementia received necessary care and services related to dementia, specifically in the assessment and management of elopement risk. The resident’s admission record documented dementia, bipolar disorder, and insomnia, and the history and physical indicated the resident lacked capacity to understand or make decisions. The MDS assessment showed impaired cognition for daily decision-making and a need for supervision with ADLs. The resident’s care plan identified cognitive status that could increase the risk of wandering or exit seeking and called for assessment of elopement/wandering risk on admission, quarterly, and as needed. Despite these documented conditions and risk factors, the Wander/Elopement Risk Evaluation completed for the resident on 4/6/2026 did not indicate a diagnosis of dementia or any other diagnosis impacting decision-making and concluded the resident was not an elopement or wander risk. During interviews, LVN3 confirmed that the evaluation omitted dementia and other cognition-impacting diagnoses and still indicated no elopement risk, and also stated not knowing whether the resident had a dementia diagnosis. The DON later verified that the evaluation showed no dementia or decision-making diagnosis and that, based on the resident’s assessments and risk factors, the resident had multiple risks for elopement that should have triggered an elopement risk designation under the facility’s own evaluation instructions. On 4/11/2026, nursing progress notes documented that during morning rounds the resident was found missing from the room after having been awake all night and seen self-propelling in a wheelchair in the hallway. A facility search and Code Green were initiated, and local police were notified when the resident could not be located. Review of surveillance video from the front lobby showed the resident in a wheelchair near the front door while a housekeeper worked nearby. After the housekeeper briefly left the camera’s view, the resident rapidly self-propelled around a retractable barrier and exited through an unlocked front door. The housekeeper re-entered the lobby seconds later and continued working while the resident was no longer present. This sequence of events demonstrated that the inaccurate elopement risk assessment contributed to the resident eloping from the facility.
Failure to Obtain Valid Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident and/or responsible party were properly informed and provided valid consent for the use of a psychotropic medication, Depakote. The resident was admitted with diagnoses including toxic encephalopathy, lack of coordination, and anxiety disorder, and an MDS dated 1/5/2026 documented severe cognitive impairment. A History and Physical dated 10/2/2025 stated the resident did not have the capacity to understand and make decisions. Despite this, psychiatric notes from 12/9/2025 showed the resident was being managed with Depakote 500 mg TID for mood stabilization and behavioral management. Nursing progress notes from 1/28/2026 documented that staff discussed a new psychotropic medication informed consent form with the resident, including risks, benefits, side effects, and FDA black box warnings, and recorded that the resident verbalized understanding and wished to continue the medication. On 1/28/2026, a psychiatrist obtained a signed psychotherapeutic drug informed consent form from the resident for Depakote, relying on nursing input and without personally assessing the resident’s decision-making capacity. Subsequent observation and interview on 4/1/2026 showed the resident was alert but confused about place and situation and unable to verbalize understanding of administered medications. The LVN interviewed stated that a resident or responsible party consenting to psychotropic medication must have decision-making capacity and understanding of the medication, and was unaware who obtained the Depakote consent. The director of social services stated the resident did not have capacity to make medical decisions, that consent should be obtained from a responsible party or bioethics committee, and that there had been no bioethics committee discussion for this resident. The RN supervisor acknowledged it was not clinically sound to have a resident without capacity sign consent and recognized this as a deficiency. The psychiatrist later confirmed he did not assess the resident before obtaining consent and acknowledged it was a deficiency to have a resident without capacity sign consent, contrary to the facility’s Consent to Treatment policy requiring consent from a legally authorized representative when a resident lacks capacity.
Failure to Provide Ordered One‑to‑One Supervision Resulting in Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent a resident‑to‑resident altercation for a resident who had been ordered for one‑to‑one supervision. Resident 1 was admitted and later readmitted with diagnoses including unspecified affective mood disorder and psychosis, with documentation of severely impaired cognition, dependence on maximal assistance for mobility and ADLs, and lack of capacity to understand and make decisions. The resident’s care plan, initiated on 9/29/2025 and revised on 2/1/2026, identified risk for elopement based on two prior attempts to leave the facility and directed staff to conduct frequent visual checks. A psychiatric narrative note dated 1/17/2026 documented multiple attempted elopements and stated that Resident 1 required close monitoring and was placed on one‑to‑one supervision to ensure safety, with a plan to continue that level of supervision. On 2/1/2026 at approximately 7:55 AM, an altercation occurred between Resident 1 and Resident 2. Progress notes for that date and time indicated that Resident 1 entered Resident 2’s room, Resident 2 pushed Resident 1 out of the room, and both residents grabbed each other. A CNA who was familiar with Resident 1 reported that Resident 1 had mood swings, might have been confused when entering another resident’s room, and that she personally observed Resident 2 push Resident 1 out of her room on that date. Resident 2’s records showed diagnoses of schizophrenia and major depressive disorder, intact cognition, and independence with mobility and ADLs. During interviews and record review, the DON confirmed that Resident 1’s care plan did not reflect the one‑to‑one supervision ordered in the psychiatric note and acknowledged that the one‑to‑one supervision was not provided on 2/1/2026. The facility’s policies on Safety and Supervision of Residents, Comprehensive Person‑Centered Care Plans, and Wandering and Elopements stated that the environment should be as free from accident hazards as possible, that resident safety and supervision to prevent accidents are facility‑wide priorities, that care plans are to be revised as resident conditions change, and that residents at risk for unsafe wandering are to be identified and protected. Despite these policies and the documented need for close monitoring and one‑to‑one supervision, Resident 1 was not under one‑to‑one supervision at the time he entered Resident 2’s room and the altercation occurred.
Failure to Notify Resident Representative After Elopement Attempt and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident representative of a significant change in condition and safety risk following an elopement attempt. A resident with a diagnosis of dementia was admitted with documentation listing him as his own responsible party. However, subsequent assessments showed that his cognitive status had declined. An MDS dated 10/6/2025 documented severely impaired cognition for decisions of daily living and noted that he required assistance or supervision with multiple activities of daily living, including oral hygiene, toileting, dressing, transfers, and mobility. A History and Physical dated 11/19/2025 further indicated that the resident did not have the capacity to understand and make decisions. On 10/5/2025, an SBAR Communication Form documented that the resident had increased confusion and disorientation and attempted to leave the facility, stating that his daughter needed him. There was no documented evidence that staff notified any family member, guardian, or other responsible representative of this attempt to leave or the change in behavior. During interviews, an LVN confirmed that staff failed to notify the resident’s family members about the episode of confusion and elopement, and the DON stated that it is important to notify family and document which family member was notified following such behavioral changes. The facility’s policy titled “Change in a Resident's Condition or Status” stated that the facility will promptly notify the resident representative of changes in the resident’s medical or mental condition or status following a significant change in physical, mental, or psychosocial status, which was not followed in this case.
Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's primary physician following a significant change of condition. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, experienced a seizure, an irregularly high heart rate (147-152 bpm), and low oxygen saturation (85%). Nursing staff provided oxygen and implemented seizure precautions, and a message was left with the physician's answering service. However, there was no documentation that the physician returned the call or that new orders were received. Interviews with staff confirmed that the physician was not reached directly and that no further action was taken to obtain medical orders or escalate the situation, such as contacting the medical director, as required by facility policy. The nurse practitioner stated that the resident should have been sent to the hospital for evaluation, and the DON confirmed that the protocol was to contact the medical director if the primary physician did not respond. The facility's policy required prompt physician response and further escalation if no timely response was received, which was not followed in this case.
Failure to Monitor Blood Sugar in Diabetic Resident During Prolonged Fasting
Penalty
Summary
A deficiency occurred when the facility failed to obtain a blood sugar level by fingerstick for a resident with diabetes mellitus who had not eaten for over six hours. The resident, who also had severe cognitive impairment and was dependent on staff for most activities of daily living, pulled out his nasogastric tube (NGT), resulting in the inability to provide nutrition from 3 p.m. to 9:30 p.m. During this period, the resident's blood sugar was not monitored, despite the care plan indicating the need to monitor blood sugar as ordered and the facility's policy requiring blood glucose checks when fasting or after significant changes in condition. Interviews with two licensed vocational nurses confirmed that the resident's blood sugar was not checked during the fasting period, even though both nurses acknowledged the importance of monitoring for hypo- or hyperglycemia in such situations. The facility's policy and procedures for diabetes care specifically indicated the need to monitor blood glucose in cases of fasting or acute changes, but this was not followed in the resident's case.
Failure to Obtain Ordered Laboratory Test for a Resident
Penalty
Summary
The facility failed to provide laboratory services as ordered by a physician for one resident. Specifically, a physician ordered a comprehensive metabolic panel (CMP) to be obtained for a resident on a specified date, but the blood sample was not collected and there was no documentation explaining why the test was not performed. Interviews with facility staff, including a licensed vocational nurse and the medical record director, confirmed that the CMP was neither completed nor documented, and the result was not available in the resident's medical record. The resident involved had multiple diagnoses, including failure to thrive, dementia, and seizure disorder, and was dependent on staff for all activities of daily living. The facility's policy required staff to process test requisitions and arrange for laboratory tests as ordered by the physician, but this process was not followed in this instance. The deficiency resulted in the resident not receiving laboratory services necessary to determine their medical and diagnostic needs.
Failure to Protect Resident from Sexual Abuse by Another Resident with Known History of Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident who had a documented history of inappropriate sexual behavior, including walking around the facility with his genitals exposed and masturbating excessively. Despite multiple documented incidents of this behavior, the facility did not implement effective interventions or closely monitor the resident exhibiting these behaviors. The care plan for the resident with inappropriate sexual behavior included a general intervention to protect the rights and safety of others, but this was not adequately followed or enforced. The resident who was abused was nonverbal, severely cognitively impaired, and completely dependent on staff for all activities of daily living, including mobility and personal care. On the night of the incident, a CNA heard noises from the resident's room and discovered the resident with a history of sexual behavior on top of the nonverbal resident, both partially undressed. The nonverbal resident was unable to communicate about the incident, and staff observed the other resident pulling up his pants and leaving the room. The facility called emergency services, and the nonverbal resident was transferred to a hospital for evaluation of sexual assault. Interviews and record reviews revealed that the facility was aware of the sexually inappropriate behaviors prior to the incident, as documented in progress notes, care plans, and medication records. However, the facility did not conduct an interdisciplinary team meeting to address the ongoing behaviors or develop more effective interventions. Staff, including the DON and Social Services Director, acknowledged that the care plan was not followed and that closer monitoring and team intervention should have occurred to prevent the incident.
Removal Plan
- The facility staff separated Resident 2 from Resident 1 and placed Resident 1 on a one-to-one supervision.
- The facility transferred Resident 1 to GACH2 via emergency services for immediate trauma evaluation.
- The facility transferred Resident 2 to GACH3 for an evaluation of inappropriate sexual behavior.
- The facility readmitted Resident 2 from GACH3 and provided one-to-one supervision.
- The facility transferred Resident 2 to GACH4 via 5150 (involuntary 72-hour psychiatric hold) due to inappropriate sexual behavior.
- The Director of Clinical and Regional Director of Operations provided training on abuse prevention education to the ADM, the DON, to all the department heads, and staff.
- The facility conducted a wide safety check for all 80 in-house residents to ask for any exposure and physical advances or touching by Resident 2.
- The licensed nurses checked seven nonverbal residents for any signs of skin discoloration to the genital areas.
Failure to Implement Required Sexual Abuse Prevention Training and Monitoring
Penalty
Summary
The facility failed to implement its Plan of Correction (POC) as required to prevent and protect residents from resident-to-resident sexual abuse. The POC, which was signed and dated, specified that a third-party consulting agency would provide directed in-service training (DIST) to staff on the prevention and appropriate response to resident-to-resident sexual abuse. The POC also outlined that monitoring and monthly activities would begin within a specific timeframe. However, documentation and interviews revealed that the third-party training had not commenced by the POC completion date, and no staff had received the required training from the outside consultant. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) confirmed that the third-party consultant had not started the abuse prevention training, and staff had not attended any such sessions. The DON acknowledged that the facility had only provided internal in-service training and that the third-party consultant had not delivered any training or monitoring as outlined in the POC. The DON also confirmed that none of the monitoring tools, clinical auditing, weekly on-site monitoring, or reporting to the state agency, as required by the POC, had been implemented. A review of facility policies indicated that staff training on abuse prevention, identification, and reporting is a required component of the facility's abuse prevention program. Despite this, the facility did not follow through with the specific actions and timelines detailed in the POC, resulting in a failure to provide staff with the necessary training and monitoring to prevent and respond to resident-to-resident sexual abuse.
Failure to Prevent and Address Sexual Abuse Due to Inadequate Monitoring and Lack of Interdisciplinary Intervention
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent sexual abuse, specifically by not closely monitoring a resident with a known history of inappropriate sexual behavior. This resident had documented behaviors of walking around the facility with his genitals exposed and masturbating excessively, as noted in multiple progress notes, care plans, and medication administration records. Despite these repeated incidents, the facility did not provide adequate supervision or interventions to prevent further inappropriate behavior. Another resident, who was nonverbal, severely cognitively impaired, and fully dependent on staff for all activities of daily living, was subjected to sexual abuse by the resident with the history of inappropriate sexual behavior. The incident was witnessed by a CNA, who observed the resident with a history of sexual behavior on top of the nonverbal resident, both partially undressed. The nonverbal resident was unable to communicate or verbalize the incident, and the event was confirmed by staff observations and subsequent medical evaluation. The facility also failed to conduct an interdisciplinary team (IDT) meeting to address the ongoing inappropriate sexual behaviors of the resident with a known history of such actions. Staff interviews and record reviews confirmed that no IDT was held to develop or implement effective interventions, despite clear documentation of repeated incidents. The lack of close monitoring and failure to convene an IDT contributed to the occurrence of sexual abuse within the facility.
Removal Plan
- The facility staff separated Resident 2 from Resident 1 and placed Resident 1 on a one-to-one supervision.
- The facility transferred Resident 1 to GACH2 via emergency services for immediate trauma evaluation.
- The facility transferred Resident 2 to GACH3 for an evaluation of inappropriate sexual behavior.
- The facility readmitted Resident 2 from GACH3 and provided one-to-one supervision.
- The facility transferred Resident 2 to GACH4 via 5150 (involuntary 72-hour psychiatric hold) due to inappropriate sexual behavior.
- The Director of Clinical and Regional Director of Operations provided training on abuse prevention education to the ADM, the DON, to all the department heads, and staff.
- The facility conducted a wide safety check for all 80 in-house residents to ask for any exposure and physical advances or touching by Resident 2.
- The licensed nurses checked seven nonverbal residents for any signs of skin discoloration to the genital areas.
Failure to Timely Develop and Review Care Plan by Interdisciplinary Team
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of appropriate hazard controls and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide and Correctly Use Special Eating Equipment for Residents
Penalty
Summary
The facility failed to provide appropriate assistance and correct use of special eating equipment for two residents who required such devices. For one resident with generalized muscle weakness, dementia, and limited range of motion in both arms, the care plan and physician orders specified the use of a plate guard during meals to prevent food spillage and assist with self-feeding. However, during observation, the plate guard was positioned incorrectly, with the opening facing the resident, resulting in food spilling onto the table. Occupational therapy notes indicated that caregivers had been educated on the proper use and positioning of the plate guard, but this was not followed during the observed meal. Another resident, diagnosed with epilepsy and dementia, had a physician order and care plan specifying the use of a divided plate during meals due to potential nutritional problems. Instead, this resident was provided with a regular plate and a plate guard, which was also positioned incorrectly. Staff interviews confirmed that the assistive devices used were not correct for these residents and that improper use could result in food spillage. The facility's policy required staff to be trained and demonstrate competency in the use of assistive devices, but this was not adhered to during the observed incidents.
Failure to Properly Label and Date Stored Food Items
Penalty
Summary
Surveyors observed that the facility failed to properly label and date food items in one of four food storage areas. During an inspection of the kitchen freezer, several items were found without food labels or dates, including light brown meat patties, a clear bag of chopped white meat, and a freezer bag with faded, unreadable labeling. Additionally, a package of unopened frozen beef chorizo and frozen ham were found with only manufacture or storage dates, lacking expiration or best-by dates. The Dietary Supervisor confirmed during the observation that all bags should have labels with the name of the contents and dates, as per facility policy, which requires all opened and partially used foods to be dated, labeled, and sealed before being returned to storage.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Obtain Informed Consent for Antipsychotic Medication Administration
Penalty
Summary
The facility failed to obtain proper informed consent for the administration of antipsychotic and mood-stabilizing medications for a resident diagnosed with schizophrenia and bipolar disorder. Upon review, the resident was readmitted with orders for risperidone, quetiapine (Seroquel), and valproic acid. Documentation showed that the resident had impaired memory recall and lacked the capacity to make medical decisions, as indicated in both the History and Physical and the Minimum Data Set. Despite this, the facility's consent forms for these medications only indicated verbal consent from the resident, with no signature from either the resident or a responsible party. Interviews with the DON and Medical Director confirmed that the resident did not have the capacity to provide informed consent and that the facility did not obtain consent from the resident's representative. The facility's policy required that informed consent be obtained from the resident or their representative prior to administering psychotropic medications, including a review of risks, benefits, and alternatives. The consent forms were completed inaccurately and did not reflect the resident's cognitive status or the need for a representative's involvement.
Failure to Provide Advanced Directive Information to Resident's Representative
Penalty
Summary
The facility failed to provide an advanced directive or information about advanced directives to the responsible party for one resident. Upon admission, the resident had diagnoses including schizoaffective disorder, developmental delay, and was recovering from colostomy surgery. The Minimum Data Set indicated the resident had severely impaired cognition and was taking antipsychotic and antianxiety medications. A review of the resident's medical records showed there was no documentation of an advanced directive or any planning related to it. Interviews with the Social Services Director (SSD) revealed that while the SSD contacted the resident's Regional Center Service Coordinator (RCSC) to request other medical forms, she did not inquire about or provide information regarding advanced directives. The RCSC confirmed that the facility did not ask about an existing advanced directive or provide information about advanced directive planning. The facility's policy requires that residents or their representatives receive written information about advanced directives upon admission, and that this information be documented in the medical record, but this was not followed in this case.
Resident Placed on Floor Mattress Without Bed Frame or Bedrails
Penalty
Summary
A deficiency occurred when a resident's mattress was placed directly on the floor without a bed frame or bedrails, contrary to the resident's care plan, which specified the use of a high-low bed in the lowest position. The resident, a female with metabolic encephalopathy, dysphagia, and a recent colostomy, was completely dependent on staff for all self-care and mobility, and had a surgical wound. Staff interviews revealed that transferring the resident from a floor-level mattress was uncomfortable and unsafe, especially when using a mechanical lift, and that this arrangement restricted staff's ability to provide appropriate care. The facility had high-low beds available that could be positioned close to the ground, but these were not utilized for this resident. Further review indicated that the facility had not provided training to staff on care practices for individuals with intellectual disabilities or on the use of floor-level mattress placement. The Director of Nursing acknowledged that alternative safety interventions were available and that the resident may have felt she was not treated equally to other residents. Facility policy required that all residents be cared for in a manner that promotes well-being, self-worth, and dignity, and that cognitively impaired residents be treated with sensitivity. The failure to provide a safe, clean, and homelike environment as outlined in the care plan led to the deficiency.
Failure to Develop and Implement Care Plan for Fall Prevention Related to Bed Height
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's preference for raising his bed to its maximum height, despite the resident being at high risk for falls. The resident had multiple diagnoses, including lack of coordination, unsteadiness, idiopathic aseptic necrosis of the femur, wrist drop, spinal cord compression, cervical spinal stenosis, COPD, and sciatica. The care plan in place identified fall risk factors such as poor balance, unsteady gait, decreased functional status, and attempts to stand unassisted, and included interventions like joint mobility assessments, ensuring the call light was within reach, and monitoring for sedation and balance issues. However, it did not address the specific issue of the resident raising his bed to the highest position, which was observed multiple times during the review period. Nursing progress notes and direct observations confirmed that the resident frequently kept his bed in the highest position and was unable to reach his call light, further increasing his fall risk. Staff interviews revealed that the resident was non-compliant with keeping the bed in a low position for safety, and the DON acknowledged that no care plan had been developed to address this behavior. The facility's policy required ongoing assessment and revision of care plans as residents' conditions changed, but this was not followed in the case of this resident's bed height preference and associated non-compliance.
Failure to Document Ordered PVR Measurements for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to provide appropriate treatment to prevent a urinary tract infection (UTI) for a resident with multiple complex medical conditions, including diabetes mellitus, acute kidney failure, and severe cognitive impairment. The physician had ordered post void residual (PVR) measurements every six hours for 24 hours, with instructions to re-insert a Foley catheter if the PVR exceeded 300 cc. Documentation showed that PVR measurements were recorded at three of the required times, but there was no documentation of a PVR measurement at the 6 AM interval as ordered. During an interview and record review, a registered nurse confirmed that the 6 AM PVR measurement was missing and acknowledged that it should have been charted, as the resident could have been retaining urine. The facility's policy required staff to monitor and document the resident's progress and responses to treatment. The lack of documentation for the ordered PVR measurement constituted a failure to follow physician orders and facility policy for monitoring and documenting treatment.
Missed Pain Medication Dose Due to Unavailable Medication
Penalty
Summary
A resident with a history of systemic lupus erythematosus, chronic pain syndrome, and unspecified dementia was admitted to the facility and had an active order for hydrocodone-acetaminophen to be administered every 8 hours for chronic pain. On the morning in question, the resident did not receive her scheduled 6 AM dose of hydrocodone-acetaminophen. Review of the Medication Administration Record confirmed the missed dose, and the nurse's progress note indicated the medication was not available and was being awaited from the pharmacy. During interviews, the resident reported that hydrocodone-acetaminophen was the only medication that effectively managed her pain and that it was not always available when requested, describing this as an ongoing issue. The nurse and DON both confirmed that the process for unavailable medications should involve contacting the pharmacy to access the emergency kit, which was not done in this instance. Facility policy indicated that effective pain management requires around-the-clock medication, but this was not achieved due to the missed dose.
Medications Lacking Expiration Dates on Bubble Packs
Penalty
Summary
Surveyors identified that the facility failed to ensure medication bubble packs for three residents were labeled with expiration dates, as required by professional standards and the facility's own policy. During observations and interviews, it was found that two bubble packs of rivastigmine prescribed for a resident with polyosteoarthritis, muscle weakness, and dementia, one bubble pack of trihexyphenidyl for a resident with schizophrenia, major depressive disorder, and bipolar disorder, and one bubble pack of lurasidone for a resident with schizophrenia, hypothyroidism, and diabetes mellitus, all lacked expiration dates. Licensed Vocational Nurses confirmed the absence of expiration dates on these medications during medication cart inspections. The residents involved had significant medical and cognitive needs, including severe cognitive impairment and requirements for moderate to maximal assistance with activities of daily living. The facility's policy on medication labeling and storage, dated 1/16/2025, specifies that medication labels must include expiration dates when applicable. Despite this, the observed bubble packs did not meet this requirement, and staff acknowledged the importance of maintaining expiration dates to prevent the administration of expired medications.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including right side sciatica, COPD, spinal stenosis, idiopathic aseptic necrosis of the right femur, cord compression, unsteadiness on feet, left wrist drop, and lack of coordination, did not have their call light within reach while in bed. The resident was dependent on staff for toileting, bathing, dressing, personal hygiene, and transferring, and was assessed as being at risk for falls due to poor balance and unsteady gait. The care plan specifically required that the call light be kept within the resident's reach and that staff respond promptly to calls for assistance. During an observation and interview, the call light was found hanging behind the head of the resident's bed, out of the resident's reach. Both the CNA and the DON confirmed that the resident would not be able to call for help or assistance if the call light was not accessible. Review of the facility's policy indicated that call lights should be accessible to residents when in bed, on the toilet, in the shower or bathing facility, and from the floor. This failure to ensure the call light was within reach constituted a deficiency in meeting the resident's needs as outlined in their care plan and facility policy.
Room Exceeded Maximum Resident Occupancy
Penalty
Summary
The facility failed to ensure that one of its resident rooms did not accommodate more than four residents, as required by regulations. During an initial tour, surveyors observed that room [ROOM NUMBER] contained five beds, although only four residents were present at the time of observation. The facility had previously submitted a waiver request to the Department of Public Health, stating that the room had ample space for wheelchairs, medical equipment, and resident mobility, and that it did not impede the ability of residents to achieve their highest practicable wellbeing. Interviews with two residents in the room revealed that they did not have complaints regarding the available space. Throughout the survey period, nursing staff were observed to have full access to provide care, administer medications, and assist residents with activities of daily living. Despite these observations and the facility's waiver request, the presence of five beds in the room constituted a failure to comply with the requirement that no more than four residents occupy a room.
Failure to Protect Resident from Physical Abuse Due to Inadequate Behavioral Management
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, resulting in one resident being physically attacked by another. A resident with a history of schizophrenia, depression, panic disorder, and anxiety disorder exhibited escalating behavioral symptoms, including panic attacks, yelling, striking objects, and grabbing staff. Despite these incidents, the facility did not revise or update the resident's behavior problem care plan after significant changes in condition, nor did it conduct an Interdisciplinary Team (IDT) meeting upon the resident's readmission following a psychiatric hold for being a danger to self and others. The care plan for the resident with behavioral issues was not updated after multiple documented episodes of panic attacks and aggressive behavior, including an incident where the resident grabbed and shook a CNA. The facility's policies required care plan revisions and IDT meetings after significant changes in a resident's condition, but these steps were not taken. As a result, the resident's ongoing behavioral risks were not adequately reassessed or managed, and individualized interventions were not updated to address the increased risk of harm to others. Subsequently, the same resident physically assaulted another resident in the facility lobby, resulting in the victim sustaining a facial injury and an orbital fracture. Witnesses and staff confirmed the altercation, and the aggressor admitted to the physical attack. The facility's failure to implement its own policies and procedures regarding behavioral assessment, care plan updates, and IDT involvement directly contributed to the occurrence of resident-to-resident physical abuse.
Lack of Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 3, had a signed informed consent for the administration of a psychotropic medication, specifically Duloxetine HCL. Resident 3 was admitted with diagnoses including anxiety disorder, major depressive disorder, and paraplegia. The resident was alert and oriented with good recall, as indicated by the Minimum Data Set. Despite being prescribed Duloxetine for polyneuropathy, the medication is classified as a psychotropic drug, necessitating informed consent. During a review, it was found that there was no informed consent documentation in either the physical or electronic chart for this medication. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) acknowledged the absence of informed consent and stated that education about the medication was provided during medication pass, but no formal consent was documented. The Director of Nursing (DON) confirmed that the facility lacked a specific informed consent policy for psychotropic medications and that the responsibility for obtaining consent was attributed to the doctor. The RN supervisor, who took the medication order, did not document obtaining informed consent. The DON recognized the risk to the resident due to the lack of documented informed consent, which should have included information on the risks and benefits of the medication.
Facility Fails to Readmit Resident Post-Hospitalization
Penalty
Summary
The facility failed to allow Resident 2 to return after hospitalization at a General Acute Care Hospital (GACH), despite being medically stable. Resident 2, who has a history of bipolar disorder and schizoaffective disorder, was initially transferred to the hospital under a 5150 hold due to a mental health crisis involving damaging medical equipment. After being deemed stable for discharge back to the skilled nursing facility, the facility did not permit the resident's return, citing an inability to meet the resident's care needs. Interviews with the facility's Administrator and Director of Nursing revealed concerns about the resident's safety and fire risk, which they believed could not be managed at their facility. Despite the GACH's social worker's attempts to facilitate the resident's return, the facility did not respond, leaving the resident at the hospital for over three weeks. The facility's policies on bed hold and transfer or discharge were reviewed, indicating that residents should be allowed to return post-hospitalization, regardless of payer source, but this was not adhered to in Resident 2's case.
Failure to Maintain Clean and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, sanitary, and accident-free environment in two shower rooms, identified as Shower Room A and Shower Room B. During an observation, a soiled and wet Mepilex dressing was found on the floor of Shower Room A, and a soiled and wet face towel along with hair on the water drain was observed in Shower Room B. These observations were made in the presence of the Social Services Director (SSD). Housekeeping staff, when called to observe the conditions, confirmed that the shower rooms were not clean and acknowledged that the Mepilex dressing, face towel, and hair should not have been left on the floor. The Director of Nursing (DON) stated that the shower rooms should be cleaned after each use, which aligns with the facility's policy and procedures. The facility's policy on Cleaning and Disinfection of Environmental Surfaces, revised in August 2019, requires that housekeeping surfaces be cleaned regularly, when spills occur, and when visibly soiled. Additionally, the policy on providing a homelike environment, reviewed in January 2024, emphasizes the importance of maintaining a safe, clean, comfortable, and homelike environment for residents. The failure to adhere to these policies resulted in the observed deficiencies.
Inadequate Supervision of Resident by CNA
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident, leading to a potential risk of accidental injuries. The resident, who was admitted with diagnoses including urinary tract infection, chronic obstructive pulmonary disease, and unspecified dementia, was observed to have severely impaired cognitive skills and was totally dependent on staff for activities of daily living. During an observation, a Certified Nursing Assistant (CNA) was found asleep in the resident's room while the resident was lying in bed with eyes closed. This lack of alertness and supervision by the CNA posed a risk of accidents, as the CNA was not in a position to respond to any immediate needs or emergencies of the resident. Interviews with staff, including another CNA and a Registered Nurse, confirmed that the CNA was asleep and acknowledged that staff should remain awake and alert while on duty to prevent accidents and respond to residents' needs. The Director of Nursing also stated that staff should not be napping while on duty, as it affects resident care. The facility's policy on Safety and Supervision of Residents emphasized the importance of training employees to identify and report accident hazards and to provide adequate supervision to prevent avoidable accidents.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences as indicated on their meal ticket, which was part of a physician-ordered diet. The resident, who was on a renal regular no added salt diet due to chronic kidney disease and depression, expressed that they did not like mocha mix, a non-dairy creamer, which was consistently included on their meal tray. Despite the resident's cognitive skills being intact and their preferences being documented as very important, the dietary staff continued to provide mocha mix, as it was incorrectly listed as a preference on the meal ticket. The Dietary Supervisor acknowledged the resident's dislike for mocha mix but did not consult with the Registered Dietitian to find an appropriate substitute, despite having alternatives available such as rice milk, soy milk, and almond milk. The facility's policy stated that the dietitian and nursing staff should address any conflicts between nutritional needs and resident preferences, but this was not followed. This oversight resulted in the resident repeatedly receiving a meal component they did not want, highlighting a failure in communication and adherence to the facility's policies regarding resident food preferences.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to provide and document preparation and orientation for a safe and orderly facility-initiated discharge for a resident. The resident, who was cognitively intact and had a history of systemic lupus erythematosus, schizophrenia, prediabetes, and major depressive disorder, was not involved in the post-discharge planning process. The family member responsible for the resident was also not involved in selecting a new location for discharge and was not offered any tours of the facilities mentioned in the discharge paperwork. The facility's policy required that a post-discharge plan be developed and reviewed with the resident and/or their family at least 24 hours before discharge. However, there was no documentation of such a plan being developed or discussed with the resident or their family member. The Director of Nursing (DON) confirmed that there was no post-discharge plan for the resident and that there was no follow-up with the resident or family member regarding the discharge plan since the initial notice was given. Interviews with facility staff revealed that the family member received a packet of discharge papers, but there was no documentation to confirm the date of receipt. The family member stated they needed more time to find a home for the resident and was not involved in the discharge planning process. The Social Service Director acknowledged the importance of offering tours and discussing the appeal process for discharge, which was not done in this case. The facility's policy emphasized the resident's right to remain in the facility and required specific criteria and documentation for facility-initiated discharges, which were not met in this instance.
Failure to Protect Resident's Belongings
Penalty
Summary
The facility failed to ensure the protection of a resident's belongings, specifically $40, which was reported missing by the resident. The resident, who was cognitively intact and had been admitted with diagnoses including congestive heart failure and chronic obstructive pulmonary disease, reported the loss on 8/17/24. A licensed vocational nurse (LVN) searched for the missing money but was unable to locate it. However, the LVN did not report the incident to the social service designee (SSD) nor fill out the required Theft and Loss Form, as per the facility's policy. The director of staff development confirmed that there was no documentation of the missing money being found and acknowledged that the proper procedure was not followed. The director of nursing was also unaware of the complaint and stated that the facility would typically replace small amounts of money if not found. The facility's policy, reviewed earlier in the year, mandates that all reports of theft or misappropriation of resident property be promptly and thoroughly investigated, which was not adhered to in this case.
Failure to Implement Blood Pressure Parameters for Medications
Penalty
Summary
The facility failed to ensure that a resident with congestive heart failure received treatment and care in accordance with professional standards of practice. The resident was administered Metoprolol Tartrate and Hydralazine without blood pressure parameters, which are essential to prevent hypotension. The resident's care plan indicated a risk for fluctuating blood pressure but did not specify acceptable limits for these medications. The Medication Administration Record documented the administration of these medications but did not include how the resident's heart rate was assessed. Interviews with the Director of Staff Development, Director of Nursing, and the Pharmacy Consultant revealed that blood pressure parameters should have been included in the medication orders to prevent the risk of hypotension. The facility's policy on medication and treatment orders emphasized consistency with safe and effective order writing, which was not adhered to in this case. The lack of parameters placed the resident at risk for low blood pressure, which could lead to serious health complications.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to potential inadequate care. Resident 33's care plan was not updated to reflect the current physician orders for tube feeding. The resident, who was admitted with diagnoses including gastrostomy, dysphagia, and chronic gastritis, was receiving tube feeding at a rate of 35 ml/hr as per the physician's order dated 7/8/2024. However, the care plan still indicated a rate of 40 ml/hr. This discrepancy was observed during a visit on 7/23/2024, where the tube feeding was running at the correct rate of 35 ml/hr, but the care plan had not been updated accordingly. Similarly, Resident 83's care plan was not revised to reflect the current physician orders for antibiotic therapy. The resident, who was readmitted with conditions including an elevated white blood cell count and a urinary tract infection, was initially receiving Meropenem and Vancomycin as per the care plan revised on 7/9/2024. However, the physician's order dated 7/20/2024 indicated a change in the Vancomycin dosage to 750 mg, which was not updated in the care plan. During an observation on 7/23/2024, the resident was receiving the correct dosage of Vancomycin, but the care plan still reflected the outdated dosage. The Director of Nursing acknowledged that the care plans for both residents were not revised to reflect the current physician orders. The facility's policy requires care plans to be updated with any change in condition, upon admission, quarterly, or as needed. The failure to update these care plans as per the physician's orders could potentially result in unmet needs and inadequate care for the residents.
Deficiency in Staff Competency and Training Documentation
Penalty
Summary
The facility failed to maintain yearly staff competency and mandated reporting training for elder and dependent adult abuse for two out of five sampled staff members. Specifically, the employee files for two Certified Nursing Assistants (CNA 3 and CNA 4) were missing records of annual competency skills checks and mandated abuse reporting training for several years. CNA 3's file lacked these records from 2018 to 2022, while CNA 4's file was missing them for 2022. This deficiency was identified during a review of employee files conducted on July 25, 2024, with the Director of Staff Development (DSD), who acknowledged the missing records and attributed the issue to previous staff members possibly misplacing the files. The DSD, who assumed her role a year prior, stated that she has been actively working on Quality Assurance Performance Improvement (QAPI) action plans to ensure all staff are trained according to standard practices and that employee files are updated. Despite these efforts, the deficiency highlights a lapse in maintaining proper documentation of staff training and competencies, which is crucial for ensuring the quality of care provided to residents. The facility's policy requires personal records, including training and performance evaluations, to be retained for at least five years, but this was not adhered to in the cases of CNA 3 and CNA 4.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with schizophrenia and heart failure. Upon admission, the resident was prescribed Risperidone, an antipsychotic medication, but the medication was discontinued the day after admission without consulting the resident's physician or psychiatrist. The Director of Nursing (DON) decided not to resume the medication as the resident did not display any behavioral issues during their stay, despite the resident's history of schizophrenia and the lack of a comprehensive evaluation. Additionally, the facility did not conduct the required psychology consultations ordered by the resident's physician on two separate occasions. The psychology evaluation was missed, which hindered the ability to determine the necessary behavioral health services for the resident. The resident's care plan, which was initiated shortly after admission, was not revised quarterly as required, nor was it updated to reflect any changes in the resident's condition or to evaluate the effectiveness of the interventions. The facility's policies and procedures for behavioral assessment, psychotropic medication use, and care plans emphasize the need for comprehensive assessments and timely revisions of care plans. However, these protocols were not followed, leading to a deficiency in providing appropriate behavioral health services to the resident. The failure to adhere to these policies resulted in inadequate care and follow-up for the resident's behavioral health needs.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage of controlled and non-controlled medications for a resident during medication administration. During an observation, a Licensed Vocational Nurse (LVN) prepared ten medications for a resident and left them unattended on a medication cart countertop while attending to another resident. This included lacosamide, a controlled medication with potential for dependence and abuse. The LVN acknowledged that medications should not have been left unattended due to the risk of diversion and accidental exposure. Additionally, the facility did not ensure proper labeling of insulin for another resident, as observed during an inspection of a medication cart. The insulin vial was found with two different hand-written dates, which was not in accordance with the manufacturer's requirements and the facility's policy. This discrepancy made it unclear when the insulin was removed from the refrigerator or opened, potentially affecting its efficacy and safety. The Director of Nursing (DON) confirmed that the insulin vial should be labeled with an opened date and discarded after 28 days if stored at room temperature. The failure to properly label the insulin could lead to the administration of expired insulin, posing a risk of hyperglycemia or hypoglycemia for the resident.
Improper Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to observe proper food storage and handling practices, as evidenced by two specific incidents. During an initial kitchen tour, a package of cookies was found opened and undated on a shelf in the kitchen's pantry. The cook acknowledged that all packaged foods should be stored in a new container and dated immediately after opening to prevent spoilage and potential contamination. The Registered Dietitian confirmed that opened dry foods should be repackaged and dated to avoid contamination by insects or rodents, which could lead to foodborne illnesses if consumed by residents. Additionally, during a lunch tray line observation, a cook was seen rinsing a towel in the sink and then returning to serve food without washing his hands. The cook admitted forgetting to wash his hands, acknowledging the risk of contaminating the food. The Director of Staff Development and the Director of Nursing emphasized the importance of handwashing to prevent cross-contamination and potential foodborne illnesses. The facility's policies on food storage and hand hygiene were reviewed, highlighting the expectation for staff to adhere to safe food handling and sanitation standards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for six residents. Restorative Nursing Aide 1 used inappropriate cleaning agents on a cloth gait belt after assisting a resident with walking exercises. The cloth gait belt, made of porous fabric, was cleaned with Super Sani-Cloth disposable wipes, which are only suitable for hard, non-porous surfaces. This improper cleaning method was confirmed by the Infection Preventionist Nurse, the Director of Maintenance and Housekeeping, and the Director of Nursing, who all emphasized the importance of following manufacturer instructions to prevent the spread of infection. Another deficiency was observed with Resident 85, whose urinals were found hanging on the inside of a trash can next to their bed. The resident, who required assistance for various activities and was frequently incontinent, stated that the urinals were placed there for accessibility. However, this practice was verified by a Licensed Vocational Nurse as inappropriate and potentially leading to infection control issues. The Director of Nursing confirmed that urinals should be placed in designated holders to prevent such risks. Additionally, the facility failed to disinfect medication trays and cart countertops between resident room visits during medication administration for four residents. Licensed Vocational Nurse 1 did not disinfect the trays and cart surfaces after administering medications, which was acknowledged as a lapse in infection control practices. The Director of Nursing stated that proper disinfection procedures should be followed to prevent the spread of infection, as outlined in the facility's policies and procedures.
Failure to Maintain Safe Environment Due to Damaged Floor
Penalty
Summary
The facility failed to maintain a safe and homelike environment for a resident by not repairing a damaged floor surface in the resident's room. The floor, made of vinyl, had a crack and chip running across its entire length, creating an uneven and slanted surface approximately half an inch high. This condition was observed during a survey, and the resident confirmed that the damage had been present since their admission to the room several months prior. The resident expressed dissatisfaction with the room and the facility, indicating a desire to transfer closer to family. Interviews with facility staff, including a CNA, the Director of Staff Development, the Environment Aide, and the Director of Maintenance and Housekeeping, confirmed awareness of the floor damage and its potential risk for trips and falls. The damage had been present for several months, and although the Director of Maintenance had contacted a third-party company for repairs, no specific timeframe for the repair was provided. The facility's policy on maintaining a homelike environment emphasizes providing a safe, clean, and comfortable setting, which was not upheld in this instance.
Failure to Create Care Plan for Prescribed Medication
Penalty
Summary
The facility failed to create a care plan for a resident who was prescribed Diflucan (Fluconazole) to treat fungal pneumonitis. The resident, who was cognitively intact and required varying levels of assistance for daily activities, was admitted with diagnoses including an elevated white blood cell count, adult failure to thrive, and a urinary tract infection. Despite the physician's order for Diflucan, the resident's care plan did not include this medication, which is essential for evaluating the effectiveness of the treatment and ensuring the resident is not given unnecessary medication. During a review, the Director of Nursing acknowledged the absence of a care plan for Diflucan and emphasized the importance of updating care plans when new physician orders are received. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's needs. The lack of a care plan for the prescribed medication indicates a failure to adhere to this policy, potentially impacting the resident's care and treatment outcomes.
Incorrect LALM Setting for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for Resident 190 by not ensuring the correct setting of the low air loss mattress (LALM), which is crucial for wound management. Resident 190 was admitted with a stage three pressure ulcer on the back and unstageable pressure ulcers on the right ankle and heel. The resident's care plan and physician orders specified the use of a LALM set according to the resident's weight and comfort, with checks on placement and functioning every shift. However, during an observation, it was found that the LALM was set for a weight of 200 lbs, while Resident 190 weighed 145 lbs, indicating a discrepancy in the mattress setting. The Treatment Nurse acknowledged that the LALM settings should match the resident's weight to prevent delayed wound healing and worsening of the wound. The Director of Nursing confirmed that licensed staff are responsible for monitoring the LALM settings and that incorrect settings constitute a deficient practice. The facility's policy on pressure ulcer prevention emphasizes the importance of selecting appropriate support surfaces based on various factors, including the resident's weight. The operator's manual for the LALM also specifies setting the control knob to the patient's weight, which was not adhered to in this case.
Failure to Clarify Medication Strength and Dose
Penalty
Summary
The facility failed to clarify the strength and dose on a physician order for docusate sodium liquid for a resident, which had the potential to result in the resident receiving an inadequate or excessive dosage. The resident, who was rarely or never understood and required full assistance for activities of daily living, was observed receiving a 25 mL dose of docusate sodium liquid during a medication pass. However, the physician order did not specify the medication's strength or concentration, only the volume to be administered. Interviews with the LVN and the Director of Nursing confirmed the importance of clarifying the physician order to include the dose and strength of the medication. The facility's policy and procedure documents also indicated that medication orders must include the name and strength of the drug, dosage, and frequency of administration. The lack of clarity in the physician order could lead to the resident not being treated for constipation or experiencing episodes of diarrhea, increasing the risk for hospitalization.
Inadequate Competency in Sanitizer Testing by Dietary Staff
Penalty
Summary
The facility failed to ensure that the Dietary staff had the appropriate competencies and skills, specifically in the use of QT-40 test paper for checking Quaternary Ammonium Compounds sanitizer concentration. During an observation, a Dietary Aide (DA 1) was unable to verbalize and follow the manufacturer's guidelines for the test strips, which require the strip to be left in the solution for 10 seconds before comparison. DA 1 removed the strip immediately and was unsure of the correct sanitizer concentration level, which should be 200 parts per million (PPM) according to the facility's records. This failure could potentially lead to cross-contamination and unsanitized food preparation areas, posing a risk of foodborne illness to the 88 residents receiving food from the kitchen. The Registered Dietician, serving as the temporary Dietary Supervisor, was unaware of whether all kitchen staff had completed their annual competencies, as she had only recently assumed the position. DA 1's records showed a competency evaluation was completed in December 2023, but the Director of Staff Development and the Director of Nursing indicated that the Dietary Supervisor should have ensured proper education and evaluation of the Dietary Aides. The facility's policy on infection prevention and control requires personnel to be trained on relevant procedures, but the deficiency suggests a lapse in ensuring that training was effectively implemented.
Failure to Maintain Sanitary Environment and Prevent Fly Infestation
Penalty
Summary
The facility failed to maintain a sanitary environment and prevent an infestation of flies in and around the waste segregation and disposal area. During an observation, two open trash bins were found filled with food leftovers, with trash spilled over and flies swarming around them. Interviews with the Maintenance Supervisor, Director of Nursing, Infection Preventionist Nurse, and Environment Aide confirmed that the presence of flies is a potential risk for infection outbreaks and is against the facility's infection prevention policy. The facility's pest control program, managed by a third-party company, had previously recommended covering trash to prevent pest issues. A review of the pest control company's invoices revealed multiple observations of uncovered trash and recommendations to address this issue. Despite regular pest control visits, the facility failed to implement these recommendations effectively, leading to the observed deficiency. The facility's policy on pest control emphasizes maintaining an effective program to keep the building free of insects and rodents, yet the presence of flies in the conference room and their potential to spread germs was noted during an exit conference with facility staff.
Violation of Resident Room Occupancy Limits
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents in a room to no more than four. During an initial tour of the facility, it was observed that one resident room contained five beds, which is a violation of the regulation. This deficiency was noted during a survey conducted from July 22 to July 25, 2024. The facility had submitted a letter to the Department of Public Health requesting a waiver for this room, stating that there was ample space to accommodate wheelchairs, medical equipment, and allow for the mobility of ambulatory residents. The facility claimed that the health and safety of the residents were not compromised, and the room arrangement did not impede the residents' ability to achieve their highest practicable well-being. During the survey, two residents were observed in the room with five beds, and both were not interviewable. Interviews with Certified Nursing Assistants (CNAs) assigned to the room revealed that they believed there was sufficient space to provide care and perform daily activities. CNA 5 and CNA 6 both stated that they had no concerns regarding the space in the room, and they were able to provide necessary treatments, administer medications, and assist residents with their daily routines. Despite these observations, the presence of five beds in a single room remains a violation of the regulatory standards for resident room occupancy.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident was informed in advance of the risks and benefits of psychoactive and hypnotic medications, violating the resident's right to make an informed decision. The resident, who was admitted with diagnoses including schizophrenia, depression, and type 2 diabetes, was found to have moderately impaired cognition and was taking hypnotic medication. The facility's records indicated that informed consent for medications such as Zyprexa and Lorazepam was not properly documented, as the consents did not include the name of the physician who obtained them, and there was no evidence that informed consent was obtained prior to the initiation of therapy. The facility's policy on psychotropic medication use and informed consent required that residents receive antipsychotic medication only when necessary and that the attending physician inform the resident or their representative of the medication or treatment orders, including adverse side effects. However, the Director of Nursing acknowledged the lack of documented evidence of informed consent from the physician, which was a deviation from the facility's policy. This oversight in obtaining and documenting informed consent contributed to the deficiency identified during the survey.
Failure to Initiate Zyprexa Care Plan for Resident
Penalty
Summary
The facility failed to initiate a care plan for the administration of Zyprexa, an antipsychotic medication, for a resident diagnosed with schizophrenia, depression, and type 2 diabetes. The resident was admitted on 6/12/2024 and was noted to have moderately impaired cognition and lacked the capacity to understand and make decisions. Despite a physician's order dated 7/2/2024 to administer Zyprexa 5 mg at bedtime for schizophrenia manifested by aggressive behavior, no care plan was developed to address the administration of this medication. During a review on 7/11/2024, the Director of Nursing acknowledged the absence of a care plan for Zyprexa, emphasizing the importance of having measurable objectives to meet the resident's needs and desired outcomes. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables to address the resident's physical, psychosocial, and functional needs, which was not implemented in this case.
Lack of Supervision in Smoking Patio Leads to Resident Altercation
Penalty
Summary
The facility failed to provide direct supervision to residents in the smoking patio, as required by their Smoking Policy. On 6/20/2024, Resident 1, who had severe cognitive impairment and a history of schizophrenia, depression, and epilepsy, was left unsupervised in the smoking patio. This lack of supervision led to Resident 1 physically assaulting Resident 2 and Resident 3, hitting them on the chin and forehead, respectively. Resident 1's medical records indicated severe cognitive impairment and a lack of capacity to make medical decisions. The resident was on antipsychotic and antidepressant medications. The incident occurred during a time when the smoking patio was supposed to be supervised, but staff were not present. Interviews with residents and staff confirmed that no staff were present in the smoking patio after the receptionist left at 5 PM, despite the facility's policy requiring supervision during smoking hours. The Director of Nursing acknowledged that staff should have been present to prevent such incidents, and the facility's policy clearly stated that residents with smoking privileges requiring monitoring should have direct supervision at all times. The absence of staff during the incident on 6/20/2024 allowed for the altercation between residents, highlighting a breach in the facility's policy and procedure for resident safety during smoking breaks.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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