Lake Balboa Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Van Nuys, California.
- Location
- 16955 Vanowen Street, Van Nuys, California 91406
- CMS Provider Number
- 056180
- Inspections on file
- 39
- Latest survey
- April 12, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Lake Balboa Care Center during CMS and state inspections, most recent first.
Missing Care Plans for Vaccine Refusal and Psychotropic Medication Use: The facility did not develop individualized care plans for several residents who refused influenza, pneumococcal, COVID-19, and/or RSV vaccines, despite records showing varying cognitive status and consent refusals by residents or family members. The facility also lacked a care plan for a resident receiving Seroquel for bipolar disorder and clonazepam for anxiety, and RN confirmed the omission during record review.
A resident with type 2 DM and Parkinson’s disease received Novolog insulin injections without proper rotation of injection sites. MAR review showed repeated use of the same abdomen and arm areas, and the DON acknowledged multiple instances where the sites were not rotated. The facility policy required meds to be given per orders, and the Novolog label directed staff to rotate injection sites to avoid using the same spot for each injection.
A resident with type 2 DM and Parkinson's disease received Novolog insulin injections without proper site rotation. The MAR showed repeated injections in the same abdomen and arm areas, and the DON acknowledged multiple instances where sites were not rotated. The facility policy required medications to be given per orders, and the Novolog label instructed rotation of injection sites to reduce the risk of lipodystrophy.
Infection Control Lapses With Ice Machine, PPE Use, EBP Placement, and Soiled Bathroom Equipment: A kitchen ice machine had black substances inside the ice compartment bin, and the DS stated the buildup should have been cleaned and could contaminate ice. A resident on EBP for MDRO urine was turned and repositioned by a CNA without an isolation gown, and another resident with a PICC line was not placed on EBP despite staff noting infection risk. A soiled toilet seat cover was also left on a toilet riser in a resident bathroom, and staff stated it should have been removed after use.
Dry, Tough Roast Beef Served at Lunch: Two residents were observed struggling with roast beef that was dry, tough, and difficult to chew during lunch. One resident with DM and malnutrition ate the other items but not the meat, while another resident with dysphagia and malnutrition said the meat was like shoe leather and could not be eaten. The DS confirmed the au jus was missing and the meat was dry and tough, and RN 2 also stated it should not have been served.
Improper Quat Sanitizer Concentration in Kitchen: The Dietary Supervisor observed a red bucket of quat used to sanitize kitchen work and food prep surfaces, but test strips showed the solution was only 100 ppm instead of the required 200 ppm. The solution was retested with fresh quat and again read 100 ppm. Facility policy stated the sanitizer concentration must be tested for effectiveness and replaced when readings are below 200 ppm.
Improper disposal of garbage and refuse was observed when one black dumpster was overfilled and not completely closed, and eight transparent trash bags containing soiled diapers, gloves, empty glove boxes, and other trash were piled on the concrete in the dumpster enclosure. The DSD and DON stated the dumpster should be closed and other waste placed in lidded bins, and the facility policy required outside trash areas to be kept clean, sanitary, safe, and compliant while avoiding overfilling bags or bins.
Incomplete Documentation of Physician Order Change: An IPN failed to document the full physician conversation regarding a resident’s vancomycin order. The resident had DM, HTN, elevated WBC, and VRE, and was receiving vancomycin for C-diff prophylaxis. The Antibiotic Time Out showed no active infection, and the IPN stated the physician initially discontinued the medication before it was continued after FM request, but that initial discontinuation was not documented in the medical record.
Insufficient square footage was identified in multiple resident rooms after surveyors found that 10 of 23 rooms did not meet the required 80 sq. ft. per resident. The facility’s waiver request and room measurements showed several double- and quadruple-occupancy rooms providing only 77.5 to 78.5 sq. ft. per resident, although residents were observed moving freely and staff had adequate space to provide care.
Surveyors found that the facility’s RDs did not perform in-person, nutrition-focused physical assessments or direct interviews for two residents receiving hemodialysis, despite significant conditions such as ESRD, DM, and moderate protein-calorie malnutrition. The Dietary Supervisor obtained food preferences, and the RDs completed Nutrition Evaluation and RDN Reviews remotely or based solely on chart review and DS input, without speaking to the residents or their representatives or physically assessing chewing, eating ability, or skin integrity. One RD worked entirely remotely and stated she did not need face-to-face assessments, while the on-site RD acknowledged a high-risk dialysis resident should have been seen but was never assessed due to the resident’s dialysis schedule. These practices conflicted with facility policies, RD job descriptions, and the Academy of Nutrition and Dietetics’ Nutrition Care Process, which call for assessment data from interview, observation, and collaboration with the client.
The facility failed to follow its I&O policy and physician-ordered fluid restrictions for two dialysis residents with ESRD and other comorbidities. One resident with a 1,500 mL/day fluid restriction repeatedly received between 1,650 mL and 3,300 mL per day based on combined CNA and nurse documentation, despite clear orders and care plan breakdowns by shift. Another resident with a 1,000 mL/day restriction had multiple days where CNA documentation showed intake between 1,050 mL and 1,220 mL. The ADON acknowledged that CNAs provided fluids without proper coordination with licensed staff, that nurses did not adequately monitor or total 24-hour intake, and that the facility’s written I&O procedures for documenting and totaling fluids each shift were not effectively implemented.
Surveyors found multiple failures in food handling and storage, including an undated bag containing a cup of food brought in by a family member for a resident stored in a kitchen refrigerator, a container of strawberries with visible mold-like discoloration that had not been checked for spoilage, and an opened package of hamburger buns stored without an open date. The Dietary Supervisor acknowledged that family-prepared foods should be discarded after 24 hours, that staff had not checked the strawberries for spoilage, and that all opened food items should be labeled with an open date, as required by facility policies on foods brought by visitors, storing produce, and labeling and dating foods.
A resident with end stage renal disease, type 2 DM, and dependence on renal dialysis had a documented CCHO/renal diet and a care plan intervention to honor personal dietary choices, with the RDN noting a preference for soup at lunch and the meal card specifying soup as an added lunch item. During a lunch observation, the DON noted that the resident's tray did not include soup despite the meal ticket indicating it should, and the Dietary Supervisor later confirmed that kitchen staff are required to follow meal tickets and that the resident's preference was not honored, contrary to the facility's food preference policy.
A resident with severe cognitive impairment and multiple medical conditions had their detailed discharge summary and post-discharge plan, including full identifying and clinical information, mistakenly included in another resident’s discharge packet. An RN acting as supervisor relied on discharge paperwork pre-printed and placed in the chart, verified only the initial pages for the correct name and medication list, and failed to review all pages, resulting in the other resident receiving confidential PHI. The DON and RN acknowledged this as a HIPAA violation, contrary to facility policy requiring protection of all resident health information.
A physical therapist did not wear an isolation gown while providing range of motion exercises and repositioning a resident on enhanced barrier precautions for an MDRO infection and indwelling catheter. Despite clear signage and facility policy requiring gown and gloves for high-contact care, only gloves and a mask were used during the therapy session.
A resident with Parkinson's disease and dysphagia was assisted by a CNA who stood over him during feeding, contrary to the facility's policy requiring staff to sit at eye level to maintain dignity. The CNA stated it was easier for her to stand, despite the Director of Nursing's directive to assist residents in a sitting position.
A resident's privacy was compromised when an LVN left their electronic health record open and unattended during a medication pass. The resident, who was dependent on staff for care, had their medication list and photo visible on a computer screen. The LVN admitted this was a HIPAA violation, as the facility's policy requires that medication carts be locked and screens closed when not in use.
A facility failed to provide non-pharmacological interventions before administering opioid pain medication to a resident with atrial fibrillation and pneumonia. Despite physician orders to attempt non-pharmacological methods like repositioning and relaxation, the resident received Percocet on multiple occasions without these interventions, increasing the risk of adverse effects.
A resident with an indwelling catheter was observed with the catheter tubing touching the floor, contrary to the facility's infection control policy. The resident, who required substantial assistance due to mildly impaired cognition, was at risk of infection due to this oversight. Both an LVN and the DON acknowledged the risk of bacterial transmission from the tubing touching the floor.
The facility was found to have ten rooms that did not meet the required minimum square footage per resident during a recertification survey. Despite the deficiency, observations and interviews indicated that residents and staff did not experience issues with space for mobility or care. The facility had applied for a Room Variance Waiver, asserting that the space was adequate for residents' needs.
The facility failed to document essential pacemaker information for two residents with atrial fibrillation and cardiac pacemakers. The care plans lacked details such as the pacemaker type, insertion date, rate, and contact information, contrary to the facility's policy. Interviews with staff confirmed the oversight, and the Director of Nursing acknowledged the responsibility to obtain this information upon admission.
The facility failed to offer COVID-19 testing to visitors upon entry, contrary to its policy, and did not place a resident with E. coli bacteremia on contact isolation as ordered by a physician. The DON decided against isolation despite available private rooms and a physician's order, believing the infection was not severe enough. These actions led to deficiencies in infection control practices.
Missing Care Plans for Vaccine Refusal and Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for several residents after they refused recommended vaccinations. For Resident 7, the record showed admission with acute pyelonephritis, UTI, and unspecified dementia. The resident’s consent forms documented refusal of influenza, pneumococcal, COVID-19, and RSV vaccines by Family Member 2. The H&P noted fluctuating capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills for daily decisions. The IPN stated the resident had refused influenza, pneumococcal, COVID-19, and RSV vaccines, and also stated the facility does not develop a care plan for residents’ refusal of vaccination. For Resident 15, the record showed admission with unspecified elevated WBC count, DM, and HTN. The consent form documented refusal of influenza, pneumococcal, and COVID-19 vaccines by Family Member 3, and the vaccination consent documented refusal of RSV vaccine. The MDS indicated the resident’s cognitive skills for daily decisions were intact. The IPN stated the resident had refused influenza, pneumococcal, COVID-19, and RSV vaccines. For Resident 35, the record showed admission with unspecified MS, UTI, and essential HTN. The consent form documented refusal of influenza, pneumococcal, and COVID-19 vaccines, and the vaccination consent documented refusal of RSV vaccine. The H&P indicated the resident had capacity to understand and make decisions, and the MDS indicated cognitive skills for daily decisions were intact. The IPN stated the resident had refused influenza, pneumococcal, COVID-19, and RSV vaccines. For Resident 33, the record showed admission with unspecified asthma, fall, and weakness. The consent form documented refusal of influenza, pneumococcal, and COVID-19 vaccines by Family Member 4, and the vaccination consent documented refusal of RSV vaccine. The H&P indicated the resident had capacity to understand and make decisions, while the MDS indicated moderately impaired cognitive skills for daily decisions. The IPN stated the resident had refused pneumococcal and RSV vaccines and stated the facility does not develop a care plan for vaccination refusal unless there was a change in condition. The DON stated care plans are developed to address residents’ problems and needs and that vaccination is a medical need, but the facility did not develop individualized care plans with goals and interventions for these residents’ vaccine refusals. The facility also failed to develop a care plan for Resident 8’s use of Seroquel and clonazepam. The resident’s record showed admission with dementia, bipolar disorder, and anxiety. The MDS indicated moderately impaired cognition for daily decision-making and that the resident was mostly dependent for ADLs. The order summary showed Seroquel 25 mg, three tablets at bedtime for bipolar disorder, and clonazepam 1 mg at bedtime for anxiety. During review of the care plans, RN 2 confirmed there was no care plan addressing the resident’s Seroquel use or anxiety-related behavior requiring clonazepam, and stated individualized care plans are important so the facility can provide proper care to meet the resident’s needs.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
Licensed nurses failed to follow professional standards of practice when administering Novolog insulin to a resident with type 2 DM and Parkinson’s disease. The resident was admitted on 6/1/2023 and readmitted on 2/24/2026, and the MDS dated 3/2/2026 indicated the resident could make himself understood and understand others, but needed substantial assistance from staff for dressing and bathing. The resident had an active order for Novolog FlexPen 100 units/ml to be given subcutaneously before meals and at bedtime according to sliding scale. Review of the MAR from 3/8/2026 through 3/23/2026 showed repeated insulin administrations in the same injection areas, including the left upper quadrant of the abdomen on 3/8 and 3/9, the left arm on 3/16 and 3/17, and the left lower quadrant of the abdomen on 3/22 and 3/23. The DM care plan directed staff to administer medication as ordered. During interview and record review, the DON stated nurses were expected to rotate injection sites and acknowledged multiple instances where the resident’s insulin injection sites were not rotated. The facility policy required medications to be administered in accordance with prescriber’s orders, and the FDA label for Novolog stated to rotate injection sites from one injection to the next and not use the same spot for each injection.
Insulin Injection Sites Not Rotated
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors by not rotating insulin injection sites for one sampled resident with type 2 DM and Parkinson's disease. The resident was admitted on 6/1/2023 and readmitted on 2/24/2026, and the MDS dated 3/2/2026 indicated the resident could make himself understood and understand others, but needed substantial assistance from staff for dressing and bathing. The resident had an active order for Novolog FlexPen 100 units/mL to be given subcutaneously before meals and at bedtime. Review of the MAR from 3/8/2026 through 3/23/2026 showed repeated insulin administrations in the same areas, including the abdomen left upper quadrant on 3/8 and 3/9, the left arm on 3/16 and 3/17, and the abdomen left lower quadrant on 3/22 and 3/23. During interview and record review, the DON stated there were multiple instances where the insulin injection sites were not rotated in 3/2026 and that sites should be rotated to prevent damage to the skin tissues of the resident and medication errors. The facility policy required medications to be administered in accordance with prescriber orders, and the FDA label for Novolog stated to rotate injection sites from one injection to the next to reduce the risk of lipodystrophy and not use the same spot for each injection.
Infection Control Lapses With Ice Machine, PPE Use, EBP Placement, and Soiled Bathroom Equipment
Penalty
Summary
The facility failed to maintain infection control in the kitchen when a concurrent observation with the Dietary Supervisor found black substances inside the ice compartment bin of one sampled ice machine. When the inside of the ice compartment where the door latched was wiped with a paper towel, the towel collected black substances that adhered to it. The Dietary Supervisor stated the black substances should have been wiped away and cleaned during regular cleaning, and stated that if the substances got into the ice and were ingested, it could cause foodborne illnesses. The DON stated the ice machine should be regularly cleaned and maintained so the ice is not contaminated by pathogens, and the facility policy required the ice machine to be cleaned and sanitized monthly. The facility also failed to ensure PPE use during enhanced barrier precautions for a resident with MDRO urine. Resident 7 was admitted with toxic encephalopathy, sepsis, and UTI, had severely impaired cognition, and required substantial to dependent assistance with ADLs. The resident had a physician order for EBP due to MDRO urine. During observation, a CNA turned and repositioned the resident without wearing an isolation gown, even though the CNA stated the resident was on EBP and that a gown should have been worn when touching the resident. The IPN stated staff must wear gowns and gloves for residents on EBP during high close-contact care such as touching, repositioning, and cleaning. The facility further failed to place a resident with a PICC line on EBP. Resident 62 was admitted with reduced mobility, dysphagia, and need for assistance with personal care, and had a physician order for a right upper arm PICC line site check. During observation, the resident was repositioned and changed, and staff stated the resident was not on EBP. The IPN stated the PICC line did not place the resident on EBP, while an RN stated the PICC line placed the resident at high risk for infection and that the resident needed to be on EBP. In addition, a soiled toilet seat cover remained on the toilet riser in a resident bathroom during observation. The resident stated the dirty cover should have been thrown away, and a CNA stated it should have been removed right after use to prevent the spread of infections.
Dry, Tough Roast Beef Served at Lunch
Penalty
Summary
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature was not met when roast beef served at lunch was observed to be dry and too tough to chew for two residents. Resident 2 had diagnoses including type 2 DM and moderate protein calorie malnutrition, and his MDS indicated he could make himself understood and understand others, needed substantial assistance with dressing and bathing, and setup assistance with feeding. His order included a CCHO, NAS, regular diet with level 7 texture. During lunch dining observation, his family member repeatedly tried to cut the roast beef into tiny pieces while Resident 2 ate the other food items but did not eat the meat. During the same meal, Resident 37, who had diagnoses including dehydration, dysphagia, and protein calorie malnutrition, and whose MDS indicated moderately impaired cognition, supervision with eating, dependence for other ADLs, and some difficulty or pain while swallowing, was observed having a hard time cutting the meat into pieces. Resident 37 stated he was unable to eat because the meat was too tough like shoe leather. His order included a CCHO diet. The Dietary Supervisor reviewed the menu and confirmed roast beef au jus was served for lunch, then tested and chewed the meat for about a minute before swallowing. The Dietary Supervisor stated the au jus was missing, the meat was dry and tough, and it should not have been served to the residents. RN 2 also observed the meat and stated it looked very dry and tough and should have been noticed sooner to offer a substitute. Facility policy required staff who observe chewing problems to refer the issue to the DON and to offer a food substitute if poor intake is noticed, and the in-room dining policy stated meals would be presented attractively.
Improper Quat Sanitizer Concentration in Kitchen
Penalty
Summary
The facility failed to ensure that the Quaternary Ammonium Solution used to sanitize kitchen work and food preparation surfaces maintained a holding concentration of 200 ppm. During a concurrent kitchen observation and interview, the Dietary Supervisor showed a red bucket containing a clear quat solution and stated that it was used to sanitize work and food preparation surfaces. The Dietary Supervisor also stated that the facility kept a testing log to verify the quat concentration at 200 ppm according to the manufacturer’s guidelines, and that the bucket had already been tested for breakfast because the Sanitizer Dispenser Log had been filled for that testing period. The Dietary Supervisor tested the solution in the red bucket with a test strip, which turned orange and was identified as 100 ppm instead of the required 200 ppm. After the bucket was replaced with fresh quat solution, the solution was tested again and the strip again turned orange. The Dietary Supervisor then discarded the red bucket and stated that the quat solution would not be able to effectively disinfect work surfaces. The facility policy titled Quaternary Ammonium Log Policy stated that the quaternary sanitizer concentration would be tested for effectiveness and that the solution would be replaced when the reading was below 200 ppm.
Improper Disposal of Trash in Dumpster Area
Penalty
Summary
Improper disposal of garbage and refuse was observed at the back of the main facility building near the parking lot. During a concurrent observation and interview with the DSD, one black dumpster was seen overfilled with bagged trash and empty cartons and was not completely closed. In the same dumpster enclosure, eight transparent trash bags were observed piled on the concrete floor. The bags contained soiled diapers, gloves, empty glove boxes, and other unidentifiable trash. The DSD stated the dumpster should be completely closed and that other trash should be placed in bins. The DSD also stated the condition could attract pests, insects, and rats and was not sanitary. During a later interview and record review with the DON, the photo of the dumpster area was reviewed, and the DON stated the dumpster should be covered and other waste must be placed in bins with lids. The facility policy reviewed stated that outside trash and waste disposal areas are to be maintained in a clean, sanitary, safe, and compliant manner and to avoid overfilling bags or bins.
Incomplete Documentation of Physician Order Change
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one of eight sampled residents when the Infection Preventionist Nurse did not document that the physician initially discontinued the resident’s vancomycin on 3/24/2026. Resident 15 was admitted with diagnoses including elevated WBC, DM, and HTN, and had a physician order dated 3/21/2026 for vancomycin hydrochloride oral suspension 125 mg/5 ml by mouth daily for C-diff prophylaxis for 14 days. The resident’s MDS dated 3/23/2026 indicated cognitive skills for daily decisions were intact. The Antibiotic Time Out dated 3/24/2026 indicated the resident did not have an active infection and had a culture positive for VRE. It also documented that the IPN notified Family Member 3, who wanted the vancomycin continued until completed. The MAR showed the resident received vancomycin from 3/22/2026 through 3/31/2026. During interview, the IPN stated she called the physician on 3/24/2026, the physician initially discontinued the vancomycin, and after speaking with FM 3, the physician agreed to continue it, but the IPN did not document the initial discontinuation or the complete physician conversation. The DON stated the IPN should have documented the entire conversation and that the resident’s medical record should be complete and accurate.
Insufficient Square Footage in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that at least 80 square feet per resident was provided in ten of 23 resident rooms, including rooms 101, 103, 105, 107, 110, 112, 115, 117, 119, and 121. During the recertification survey from 4/11/2026 to 4/12/2026, surveyors observed that residents in these rooms had sufficient space to move freely inside the rooms, and there was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing staff during the observations. A review of the facility’s Request for Room Variance Waiver letter dated 4/11/2026 showed that the listed rooms did not meet the federal 80 square foot requirement per resident. The facility’s Client Accommodations Analysis documented that rooms 101, 103, 105, and 107 each measured 155 square feet for two beds, rooms 110 and 112 each measured 310 square feet for four beds, and rooms 115, 117, 119, and 121 each measured 157 square feet for two beds, resulting in 77.5 to 78.5 square feet per resident. During the resident council meeting, no concerns were raised about room size, and the facility’s policy stated that multiple resident bedrooms must measure at least 80 square feet per resident and single resident rooms at least 100 square feet.
Failure to Perform Nutrition-Focused Physical Assessments for Dialysis Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Registered Dietitians (RDs) conducted nutrition-focused physical assessments, including direct interaction with residents or their representatives, for residents receiving hemodialysis. Resident 1 was admitted with ESRD, type 2 DM, moderate protein-calorie malnutrition, and dependence on hemodialysis. The care plan for Resident 1 identified risk for nutritional problems related to chronic kidney disease, ESRD, DM, and malnutrition, and included an intervention for the RD to evaluate and make diet change recommendations as needed. The facility’s process, as described by the Dietary Supervisor (DS), was that within the first three days of admission the DS interviews the resident for food preferences, and then the RD completes the second part of the evaluation and writes recommendations based on the DS’s information. Surveyors found that RD 1, who worked remotely, completed Nutrition Evaluation and RDN Reviews without conducting face-to-face assessments or speaking with residents or their families/representatives. RD 1 stated that she relied on the DS’s information and her own education and did not need to perform in-person assessments. For Resident 1, the Nutrition Evaluation and RDN Review were completed based on record review and DS input, without RD 1 physically assessing the resident or directly interviewing the resident or representative. The DON confirmed that RD 1 worked remotely and that RD 2 was expected to check and assess newly admitted residents, but also stated that, in the DON’s view, it was acceptable for RD 1 to assess residents remotely through thorough record review. For Resident 2, who was also on dialysis and considered high risk, RD 2 acknowledged that the resident should have been seen and evaluated in person but had not been assessed because the resident was off-site for dialysis on the day RD 2 was in the facility. RD 2 stated that RD 1 had assessed Resident 2 and documented the Nutrition Evaluation and RDN Review, again without an in-person assessment. RD 2 did not answer when asked about standards of practice for RDs or what a nutrition-focused physical assessment entails. The facility’s policies and job descriptions, as well as the Academy of Nutrition and Dietetics’ Nutrition Care Process documents reviewed by surveyors, emphasized assessing nutritional status through interview, observation, and physical assessment, and collaborating with the client in developing goals and monitoring outcomes, which contrasted with the facility’s practice of remote, record-based RD assessments for these residents on hemodialysis.
Failure to Monitor and Enforce Fluid Restrictions for Dialysis Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its intake and output (I&O) policy and physician-ordered fluid restrictions for residents on dialysis. For one resident with end stage renal disease, type 2 diabetes mellitus, and dependence on renal dialysis, the physician’s order and care plan specified a 1,500 mL daily fluid restriction divided among nursing and dietary shifts. The Assistant Director of Nursing (ADON) explained that licensed nurses were to document fluids they provided on an I&O record, CNAs were to document fluids they provided in the electronic health record, and that the combined total for each 24-hour period should not exceed the ordered restriction. However, review of CNA fluid intake documentation and the licensed nurses’ I&O records from multiple dates showed that the resident’s total daily fluid intake consistently exceeded the 1,500 mL restriction, ranging from 1,650 mL to 3,300 mL per day. The ADON stated that only fluids provided by licensed nurses and from the kitchen should be offered to residents on fluid restrictions, and that CNAs should inform licensed nurses before offering fluids to such residents for proper monitoring. The ADON acknowledged that the facility failed to monitor this resident’s intake according to the physician’s order and that licensed nurses should have communicated with each other, including during huddles, to remind CNAs which residents were on fluid restrictions. This failure resulted in repeated instances where the resident received more fluid than prescribed over an 11-day period. A second resident, also with end stage renal disease, dependence on renal dialysis, and hypertension, had a physician’s order, care plan, and dietary evaluation specifying a 1,000 mL fluid restriction divided among breakfast, lunch, and dinner, with PO intake to be monitored. Review of CNA task documentation over a one-month period showed that this resident’s daily fluid intake exceeded the 1,000 mL restriction on multiple dates, with recorded intakes between 1,050 mL and 1,220 mL. During interview and record review, the ADON confirmed that the resident received more fluids than ordered on those dates and stated that licensed nurses should have monitored the resident’s fluid intake to ensure it did not exceed 1,000 mL. The facility’s written I&O policy required nursing assistants to document all fluids consumed on a daily I&O sheet, licensed staff to document fluids given with medications, and the 3–11 shift to total 24-hour intake each day, but the documented intakes show that these monitoring and documentation processes did not prevent the residents from exceeding their ordered fluid restrictions.
Failure to Properly Label, Date, and Discard Resident and Kitchen Food Items
Penalty
Summary
Surveyors identified deficiencies in food handling and storage practices in the facility kitchen during an observation with the Dietary Supervisor (DS). In one refrigerator, an undated clear plastic bag containing a cup of food brought in by a family member was stored on the bottom shelf and labeled only with a resident’s room number, without a date indicating when it was brought into the facility. The DS stated that food prepared and cooked by family members for residents was stored in this refrigerator and should be discarded after 24 hours for resident safety. Review of the facility’s policy titled “Foods brought by family or visitor” indicated that perishable prepared foods must be checked by designated dietary staff, discarded after 24 hours of storage, stored in the facility kitchen, and labeled with the resident’s name, location, and date. In the same kitchen, surveyors observed a clear plastic container of strawberries dated 2/27/2026 in Refrigerator 2 with visible black/green discoloration consistent with a mold-like substance on several strawberries. The DS acknowledged that the strawberries had not been checked for spoilage or mold and stated that staff should ensure food items are fresh and safe to use and discard them if not. In another refrigerator (Refrigerator 3), an opened package of hamburger buns was stored without an open date label. The DS confirmed the buns did not have an open date and stated that food items should have an open date label to follow guidelines on when to use the food item by. Review of facility policies on “Storing Produce” and “Labeling and dating of foods” showed requirements to check produce for spoiled items and discard them upon delivery, and to mark commercially processed, ready-to-eat cold foods stored more than 24 hours with a use-by date, which were not followed in these instances.
Failure to Honor Resident Food Preference for Soup at Lunch
Penalty
Summary
The facility failed to provide meals that accommodated a resident's documented food preferences. A resident with end stage renal disease, type 2 DM, and dependence on renal dialysis was admitted on 2/27/2026 and had a care plan for nutrition related to diabetes and chronic kidney disease with hemodialysis, which included an intervention to honor the resident's rights to make personal dietary choices. The resident's orders specified a CCHO/renal diet with regular/thin liquids. A Nutrition Evaluation and RDN Review completed on 2/28/2026 documented that the resident liked soup for lunch, and the resident's meal card indicated added food for lunch: soup. On 3/11/2026, during observation of the resident's lunch tray with the DON, it was noted that the resident did not receive soup, despite the meal card indicating that soup should be served. The DON confirmed that the resident should have had soup based on the meal card. In a subsequent interview, the Dietary Supervisor stated that kitchen staff are supposed to follow what is on residents' meal tickets at all times to honor residents' preferences and choices, and acknowledged that the facility failed to honor this resident's food preference by not serving soup at lunch. The facility's Food Preferences policy, last reviewed 2/17/2026, stated that residents' food preferences will be adhered to within reason and obtained through an initial resident screen within seven days of admission by the FNS Director.
Unauthorized Disclosure of Resident PHI in Discharge Paperwork
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s confidential personal and medical information when discharge documents for one resident were mistakenly given to another resident. The affected resident had been admitted and later readmitted with diagnoses including sepsis, Non-Hodgkin lymphoma, and hypotension. An admitting evaluation documented fluctuating capacity to understand and make decisions, and an MDS assessment showed severely impaired cognition. The resident’s Discharge Summary and Post-Discharge Plan of Care contained extensive protected health information, including full name, date of birth, admission and discharge dates, diagnoses, cognitive and physical status, nutritional status, height, weight, home address and phone number, physician and home health agency contact information, and medical equipment orders. The incident came to light when the husband of another resident who was being discharged contacted the facility’s Patient Concierge to report that the first resident’s discharge papers had been included with his spouse’s discharge paperwork. The Patient Concierge reported this to the medical records department. Review of a facility letter to the affected resident confirmed that the information disclosed included the resident’s full name, date of birth, admission date, address, discharge date, diagnosis, phone number, reason for admission, physician order for home health, height, weight, and reason for discharge. This disclosure occurred despite a facility policy stating that all resident health information is confidential, protected by HIPAA, and must not be disclosed in any form without legal authorization. Interviews with staff clarified how the error occurred. The Medical Records Assistant stated that nurses, not medical records, print discharge paperwork. The Infection Prevention Nurse, who was acting as the RN supervisor on the day in question, reported that night shift typically prepares and prints discharge paperwork and places it in residents’ physical charts. While discharging the second resident, the Infection Prevention Nurse pulled the discharge papers from that resident’s chart, checked only the first few pages to verify that the face sheet and medication list matched the correct name, and did not review all pages. As a result, the first resident’s Discharge Summary and Post-Discharge Plan of Care were inadvertently included in the second resident’s discharge packet. The Infection Prevention Nurse and the DON both acknowledged that all documents should have been checked to ensure they belonged to the correct resident and that providing these documents to another resident constituted a HIPAA violation and a breach of confidentiality.
Failure to Use Required PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when a physical therapist (PT) failed to follow infection control practices by not wearing an isolation gown while providing in-bed physical therapy services to a resident who was on enhanced barrier precautions (EBP) due to an indwelling catheter and a multidrug-resistant organism (MDRO) infection. The resident had a history of right femur fracture, urinary tract infection, and extended spectrum beta-lactamase (ESBL) producing bacteria, and was dependent on staff for multiple activities of daily living. Facility records and signage indicated that gown and gloves were required for high-contact care activities under EBP. During direct observation, the PT was seen wearing only gloves and a surgical mask while performing range of motion exercises and repositioning the resident, despite EBP signage posted at the room entrance. The infection preventionist and the director of nursing both confirmed that an isolation gown should have been worn for such high-contact activities. The facility's infection control policy also specified the use of gown and gloves for high-contact care under EBP to prevent the spread of MDROs.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance a resident's dignity and respect, as observed during a meal assistance session with a resident diagnosed with Parkinson's disease, dysphagia, and depression. The resident, who required verbal cues to feed himself, was assisted by a Certified Nursing Assistant (CNA 2) who stood over him while feeding. This practice was contrary to the facility's policy, which requires staff to sit at eye level with residents during feeding to promote dignity and allow for better observation of any swallowing difficulties. During the observation, the CNA admitted to standing over residents because it was easier for her, despite the facility's policy and the Director of Nursing's statement that staff should assist residents in a sitting position to maintain their dignity. The facility's policies on feeding dependent residents and maintaining dignity and respect were reviewed, both emphasizing the importance of sitting at eye level with residents to ensure respectful and dignified care.
Violation of Resident Privacy Due to Unattended EHR
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records when a Licensed Vocational Nurse (LVN 1) left the electronic health record (EHR) of a resident open and unattended. This incident involved Resident 94, who was admitted to the facility with acute pulmonary edema and heart failure. The resident's Minimum Data Set (MDS) indicated that they had limited ability to understand others and were totally dependent on staff for personal care tasks. During a medication pass, LVN 1 left the computer screen displaying the resident's medication list and photo open while stepping away from the medication cart to enter the resident's room. LVN 1 acknowledged that leaving the electronic chart accessible was a violation of the Health Insurance Portability and Accountability Act (HIPAA), which mandates the protection of residents' health information. The facility's policy requires that medication carts be kept closed and locked when not in sight and that resident information be kept private by closing the computer screen when not in use. This incident highlights a breach in the facility's adherence to HIPAA regulations and its own policies regarding the safeguarding of electronic protected health information (ePHI).
Failure to Provide Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions to a resident before administering as-needed opioid pain medication. The resident, who was admitted with diagnoses including atrial fibrillation and pneumonia, had intact cognition and required substantial assistance with daily activities. The physician's orders included administering Percocet for severe pain and providing non-pharmacological interventions such as repositioning and relaxation every shift. However, the Medication Administration Record showed that on three occasions, Percocet was administered without prior non-pharmacological interventions. During an interview, the Director of Nursing confirmed that non-pharmacological interventions should be attempted first to address potential external factors causing pain. The failure to do so increased the risk of adverse side effects from opioid use, such as dizziness and respiratory depression. The resident's care plan aimed to prevent interruptions in normal activities due to pain, and the facility's policy emphasized the inclusion of both pharmacological and non-pharmacological interventions in the care plan.
Infection Control Deficiency: Catheter Tubing Touching Floor
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures for a resident with an indwelling catheter. The deficiency was observed when the catheter tubing of a resident, who was admitted with multiple diagnoses including a fracture of the neck of the femur, hypertension, and acute kidney failure, was found touching the floor. This observation was made during a review of the resident's care, which indicated that the catheter tubing should be positioned below the bladder level and away from the entrance room door. The resident's Minimum Data Set (MDS) indicated mildly impaired cognition and a need for substantial assistance with personal hygiene. During an interview, a Licensed Vocational Nurse (LVN) confirmed that the catheter tubing was indeed touching the floor, acknowledging the risk of infection. The Director of Nursing (DON) also stated that the tubing should not touch the floor due to the potential for bacterial transmission, which could lead to infection. The facility's policy on indwelling urinary catheter care, last reviewed in February 2025, mandates daily catheter care to promote hygiene and reduce infection risk. Despite these guidelines, the failure to maintain the catheter tubing off the floor was identified as a deficiency in the facility's infection control practices.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in ten of its 26 rooms, as observed during a recertification survey. Specifically, the rooms in question did not meet the regulatory requirement of at least 80 square feet per resident in multiple-resident rooms and 100 square feet in single-resident rooms. The rooms identified were 101, 102, 105, 107, 110, 112, 115, 117, 119, and 121, with square footage per resident ranging from 76 to 79.5 square feet, which is below the mandated minimum. Despite this deficiency, observations and interviews with residents and staff indicated that the space was sufficient for residents to move freely and for staff to provide care without restrictions. The facility had submitted an application for a Room Variance Waiver, which was dated 3/28/2025, to address the space deficiency. The waiver request indicated that the rooms, although smaller than required, did not interfere with the free movement of wheelchairs or other mobility devices and did not adversely affect the residents' health, safety, or well-being. Interviews with residents and staff confirmed that the rooms provided adequate space for care and privacy, and no concerns were raised regarding the lack of space. The facility's policy, last reviewed in February 2025, reiterated the requirement for room sizes, highlighting the discrepancy between policy and practice.
Failure to Document Pacemaker Information for Residents
Penalty
Summary
The facility failed to provide resident-centered care by not implementing its policy on pacemaker documentation for two residents. Resident 2 was admitted with diagnoses including atrial fibrillation and a cardiac pacemaker. The care plan for Resident 2, initiated shortly after admission, lacked essential pacemaker information such as the type, date of insertion, rate, pacemaker check lab, and contact number. Interviews with the MDS Nurse and Assistant Director of Nursing (ADON) confirmed the absence of this critical information, which should have been obtained upon admission. Similarly, Resident 5 was admitted with atrial fibrillation and a cardiac pacemaker. The physician's order for Resident 5 indicated missing details like the pacemaker's model and serial number. The care plan for Resident 5 also lacked information on the pacemaker's rate, check lab, and contact number. The MDS Nurse and ADON acknowledged the missing documentation and the ADON's unsuccessful attempt to obtain the information from the resident's cardiologist. The Director of Nursing (DON) stated that it is the facility's responsibility to gather pacemaker information upon admission. The facility's policy, reviewed shortly before the incidents, required periodic checks of residents with pacemakers and documentation of specific details in the care plan. The failure to adhere to this policy resulted in incomplete medical care information for the residents, potentially affecting their care and safety.
Failure to Implement Infection Control Policies
Penalty
Summary
The facility failed to implement its infection control policy by not offering COVID-19 testing to visitors upon entry, as required by their own policy. Interviews with family members, staff, and the Infection Preventionist (IP) revealed that visitors were not offered COVID-19 tests unless they exhibited symptoms, contrary to the facility's policy. The Director of Nursing (DON) stated that testing was not offered because the facility was not experiencing a COVID-19 outbreak and lacked resources to test every visitor. However, the facility's policy indicated that all visitors should be offered self-testing with a COVID-19 antigen test upon entry, regardless of symptoms or outbreak status. Additionally, the facility failed to place a resident on contact isolation as ordered by a physician. Resident 4, who was readmitted with a diagnosis of E. coli bacteremia, was not placed in a private isolation room despite having a physician's order for contact isolation. The IP and DON acknowledged that a private room was available, but the resident was instead placed in a shared room. The DON decided against isolation, believing the infection was not severe enough to warrant it, despite the physician's order. The facility's policy on infection prevention and control requires implementing contact precautions for known infections spread by direct or indirect contact. The failure to adhere to these policies and physician orders resulted in deficiencies in the facility's infection control practices, potentially putting residents, staff, and visitors at risk of spreading infections.
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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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