Las Flores Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Gardena, California.
- Location
- 14165 Purche Ave., Gardena, California 90249
- CMS Provider Number
- 555057
- Inspections on file
- 47
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Las Flores Convalescent Hospital during CMS and state inspections, most recent first.
Two residents with intact cognition became involved in a verbal and physical altercation on a smoking patio after one resident reportedly blocked a doorway with a wheelchair and was insulted by the other. One resident threw coffee into the other’s face, and in response the second resident stood up from a wheelchair and punched the first resident in the face, causing a nosebleed, forehead hematoma, and later‑confirmed nasal and orbital fractures that required ED evaluation. Facility records and interviews confirmed the sequence of events, while the facility’s abuse prevention policy stated that residents must be free from abuse and that staff must not permit anyone to engage in physical abuse.
A resident with severe cognitive impairment and mobility dependence developed multiple pressure ulcers after staff failed to implement and update a care plan with necessary interventions such as regular repositioning and offloading. Inconsistent skin assessments and missing documentation further contributed to delayed identification and management of skin breakdown, resulting in the progression of pressure injuries.
A resident with a history of malnutrition and dysphagia experienced severe unplanned weight loss after staff failed to consistently document meal intake, provide supplements when intake was low, and implement the RD's recommendations for large-portion meals. The care plan was not updated after significant weight loss, and an IDT meeting was not conducted to address the issue, resulting in the resident requiring hospitalization and feeding tube placement.
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 did not meet safety standards, resulting in the presence of hazards and insufficient oversight.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A plan to meet a resident's most immediate needs was not created or implemented within 48 hours of admission, as required. Surveyors found no documentation or evidence that such a plan was developed for the newly admitted individual.
Staff were not provided with education on dementia care or instructed on what constitutes abuse, neglect, and exploitation, nor were they informed about how to report these incidents.
The facility failed to replace opened Emergency-Kits (E-Kits) within the required 48-72 hours, risking delays in emergency medication administration. Additionally, the facility did not follow its policy for the disposal of controlled substances, as 24 medications were destroyed without the required nurse's signature, raising concerns about potential diversion and theft. The DON admitted to not signing the destruction forms due to being busy, compromising the medication disposal process.
The facility failed to adhere to professional standards by not accurately obtaining orthostatic blood pressure readings for two residents, administering medication to the wrong site for a resident, and not following physician parameters for administering Midodrine HCI to another resident. These deficiencies could potentially lead to adverse reactions or harm.
The facility failed to complete initial and annual skills competencies for RNAs, crucial for maintaining residents' mobility. Additionally, an LVN lacked understanding of orthostatic hypotension procedures, leading to inaccurate blood pressure readings. The DON emphasized the importance of accurate readings for medication management.
The facility failed to store insulin properly, with unopened Lantus and Glargine YFGN found in a medication cart instead of refrigerated, risking decreased potency. Additionally, a soiled Clear Lax container was found, posing an infection control issue. Both the LVN and DON acknowledged these practices could negatively impact resident health.
A facility failed to implement laboratory orders for three residents, leading to delays in care and potential health risks. One resident with acute kidney failure did not have required blood tests conducted, while another with Vitamin D deficiency missed metabolic panels. A third resident with epilepsy did not receive monthly Keppra level blood draws, risking seizure management. Staff interviews confirmed these oversights, highlighting a lapse in following the facility's policy for timely laboratory services.
The facility failed to follow proper food storage practices, as observed with loosely tied cereal bags and unlabeled pancake mix and syrup in the kitchen. The Dietary Aide acknowledged the risk of pest contamination and the need for labeling to prevent serving expired products. The Dietary Service Supervisor confirmed that facility policy required proper storage and labeling.
The facility failed to include a contingency plan in its Facility Assessment, which is crucial for identifying necessary resources during regular operations and emergencies. The Administrator admitted the assessment was incomplete, lacking a plan for staffing needs during emergencies. The facility's policy indicated the assessment should guide contingency planning for events affecting resident care, such as staffing availability. CMS guidance requires facilities to document assessments for competent care during all operations.
The facility failed to provide documentation of QAPI efforts to address repeat deficiencies in Resident Rights, Laboratory Services, and Pharmacy Services. The Administrator acknowledged the absence of meeting minutes and the importance of developing a QAPI program to address these issues. The facility's policy indicated that meeting minutes should be recorded and shared, but this was not done, placing residents at risk if deficiencies were not addressed.
The facility failed to properly store five wheelchairs and one geriatric chair, leaving them outside in the rain, which could damage the equipment and prevent safe use. The DOR noted difficulties in maintaining wheelchairs, and a custom wheelchair for a resident was unusable due to being wet. The Maintenance Supervisor confirmed a lack of covered storage space, and the DON stated that medical equipment should not be stored outside.
A facility failed to obtain informed consent for psychoactive medications for a resident with diabetes, CKD, and bipolar disorder. Despite the resident's capacity to understand and make decisions, there was no documented consent for Seroquel and Duloxetine HCI in the resident's chart. Interviews with staff confirmed the requirement for informed consent, which was not met, potentially leading to the resident receiving medication without being fully informed.
A resident with COPD, hypertension, and CHF was not invited to participate in care planning meetings, despite being capable of making medical decisions. The facility's policies require residents to be invited to these meetings, but the staff failed to notify the resident, violating her rights.
Two residents in the facility were found with call lights out of reach, hindering their ability to communicate needs to staff. One resident with COPD and hemiplegia, and another with mobility issues and CHF, had call lights on the floor behind their beds. Staff, including a CNA, RN, LVN, and DON, confirmed the importance of keeping call lights accessible to prevent delays in care and ensure safety. The facility's policy mandates call lights be within reach to facilitate prompt communication.
A resident's preference for showers was not honored, despite being cognitively capable and having approval from the PT. The resident, admitted with urinary retention and dysphagia, was scheduled for showers twice a week but reported not receiving any since admission. Staff interviews confirmed the resident's capability and the facility's policy supported resident choice, yet the request was unmet, potentially affecting the resident's psychosocial well-being.
A facility failed to provide a resident's representative with the Notice of Medicare Non-Coverage (NOMNC) form within the required timeframe. The resident, who had diagnoses including dementia and required assistance with daily activities, was not given the opportunity to appeal the end of Medicare Part A skilled services due to the late delivery of the form. The facility's policy requires the NOMNC to be delivered at least two days before services end, but it was provided only one day prior.
A facility failed to submit a resident's MDS assessment within the required 14-day period after completion. The resident, admitted with conditions such as DM, CVA, and anemia, had an MDS assessment indicating total dependence on staff for certain activities. The assessment, dated 10/21/2024, was submitted late on 11/21/2024, as confirmed by the MDSN. This delay resulted in incorrect data transmission to CMS, potentially affecting care continuity.
A facility failed to create a care plan for a resident receiving Seroquel and Duloxetine, despite the resident's clear comprehension and decision-making capacity. Staff interviews and policy reviews confirmed the necessity of such a plan for individualized care, yet it was absent, indicating a lapse in policy adherence.
A resident with severe cognitive impairment and functional limitations was not provided with a necessary wheelchair for mobility, despite repeated requests. The facility failed to assess and provide the equipment upon admission, impacting the resident's ability to participate in activities and potentially affecting their physical and mental well-being. Staff interviews revealed a lack of encouragement for the resident to get out of bed, and the facility lacked a policy for providing necessary equipment.
A resident with hemiplegia, hemiparesis, and epilepsy felt isolated due to the facility's failure to provide activities outside her room. Despite her desire to participate in group activities and go outside, she was primarily offered one-on-one activities in her room. The facility's policy required activities to meet residents' needs and preferences, which was not adequately fulfilled for this resident.
Two residents with limited ROM did not receive appropriate care to prevent further decline. One resident missed timely quarterly assessments, while another did not have a prescribed elbow splint applied on several occasions. These deficiencies could hinder early detection of contractures and lead to further decline in joint mobility.
A resident with a history of GERD, dysphagia, and gastrostomy was observed lying flat during enteral tube feeding, contrary to the facility's policy requiring the head of the bed to be elevated at least 30 degrees to prevent aspiration. An LVN confirmed the oversight, acknowledging the risk of aspiration pneumonia.
A resident with a PICC line for intravenous medication was not properly monitored, as the facility failed to assess the insertion site every shift and change the dressing every seven days. The resident, who had a history of sepsis, diabetes, and hypertension, was dependent on staff for personal care. The Director of Nursing confirmed the oversight, which was against the facility's policy requiring regular monitoring to prevent infection.
A resident experienced unnecessary pain due to the facility's failure to manage their pain in a timely manner. The resident's call light was out of reach, preventing them from requesting prescribed pain relief. Despite the care plan's instructions to keep the call system accessible and respond promptly to pain complaints, these measures were not followed, leading to a delay in addressing the resident's pain.
A resident with glaucoma and cataracts did not receive prescribed eye drops due to a failure in following physician orders. The orders for Latanoprost and Cosopt were faxed but not documented or initiated, despite facility policies on handling telephone orders.
A resident's personal food item, creamy horseradish, was improperly stored at the bedside without refrigeration or labeling, contrary to facility policy. The resident, who was cognitively intact and had a history of GERD, confirmed the item was brought by her sister. Staff interviews revealed a lack of adherence to the policy requiring perishable items to be labeled, dated, and refrigerated, posing a risk of foodborne illness.
A facility failed to document a resident's transfer to a hospital from a dialysis center due to unresponsiveness. The resident, with End Stage Renal Disease and other conditions, was initially stable but later transferred without proper documentation. A nurse admitted to forgetting to document the event, which is against the facility's policy requiring such communications to be recorded.
A resident with Type 2 Diabetes Mellitus, who was cognitively intact, was forcibly administered insulin by an LVN despite refusing the treatment. The resident's blood sugar was high, and the LVN attempted to educate the resident but proceeded without consent, violating the facility's policy on resident rights. The DON confirmed that the resident's right to refuse treatment was not honored.
A CNA in an LTC facility failed to treat four residents with respect and dignity. The CNA was reported to be rude, demanding, and harsh, refusing to stay with a resident during a bowel movement and repositioning another in a hurried manner. The residents had various medical conditions requiring assistance with ADLs, and the facility's policy on resident rights was not followed.
The facility failed to maintain proper sanitation in the kitchen, as the floors were not swept and mopped according to the Cleaning Schedule. Observations revealed food residue and debris in various areas, and interviews with dietary staff confirmed lapses in cleaning practices. The Dietary Supervisor acknowledged that some areas were not cleaned daily, contrary to the facility's policy.
A resident with a history of elopement and multiple medical conditions was not adequately monitored, leading to unsupervised departures from the facility. The care plan lacked specificity in supervision type and monitoring frequency, resulting in the resident's location and behavior not being consistently checked or documented. Staff interviews confirmed the failure to perform required visual checks and update the care plan with necessary interventions.
A facility failed to report an alleged abuse incident to the state agency as required by its abuse prevention policy. A family member reported to an LVN that a CNA raised their hand as if to hit a resident, but no physical contact occurred. The LVN informed an RN, who sent the CNA home, but the incident was not reported to the state agency. The resident, who was cognitively intact and had a history of hemiplegia and hemiparesis, was at risk due to this oversight.
A resident with dementia and other conditions experienced a left humerus dislocation, which was considered an injury of unknown source. The facility submitted the initial report to CDPH but failed to provide the final investigation results within the required 5-day period, as confirmed by the DON and ADM. This was against the facility's policies and state and federal regulations.
Three residents in an LTC facility were found with smoking materials, including lighters, in their possession, contrary to the facility's smoking policy. Despite having care plans that required supervision and safe storage of smoking materials, the facility failed to implement these measures, posing significant safety risks. The residents, with varying degrees of cognitive and physical impairments, were able to access and use lighters unsupervised, highlighting a critical oversight in the facility's safety protocols.
The facility failed to report an incident of unwanted physical contact between two cognitively impaired residents to CDPH within the required two-hour timeframe, as per their policy. This delay in reporting, acknowledged by both the DON and Administrator, resulted in a delayed investigation by CDPH.
A resident with a urinary catheter experienced bladder distention and infection due to the facility's failure to document and implement physician orders. The staff did not monitor the resident's urinary output correctly and failed to document signs of a UTI. Additionally, a physician's order to flush the catheter was not documented or executed, leading to the resident's transfer to a hospital for further treatment.
A resident with a right leg cast did not receive proper cast care for five months due to lapses in initial assessment, documentation, and follow-up by the facility staff. The facility failed to adhere to its policies and procedures for cast care, leading to inadequate care for the resident's condition.
Failure to Prevent Resident‑to‑Resident Physical Abuse Resulting in Facial Fractures
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident punched him in the face during an altercation on the smoking patio. The injured resident had intact cognition, capacity to make decisions, and was dependent on staff for ADLs and transfers, using a wheelchair and mechanical lift due to his size and functional status. According to the change of condition evaluation, the resident was involved in an altercation with another resident that resulted in him being hit in the face, causing a nosebleed and a raised area on the forehead. The resident reported that he threw coffee on the other resident after being cursed at and called fat. He was transferred to a GACH for evaluation, where ED documentation noted a nosebleed, a forehead hematoma, pain, headaches, and dizziness, and a CT scan showed an undetermined nasal bone fracture and a left orbital wall medial fracture. The other resident involved in the altercation had intact cognition, capacity to make decisions, and was largely independent with ADLs, using a wheelchair for mobility but able to walk independently. Documentation indicated that this resident and the injured resident were involved in a verbal and physical altercation in which the injured resident threw coffee on the other resident’s face, after which the other resident stood up and hit him in the face. In an interview, the second resident stated he hit the first resident in the nose because coffee had been thrown in his face and that the first resident had blocked the door with his wheelchair and threatened to throw coffee again if called names. The facility’s abuse prevention and prohibition policy stated that each resident had the right to be free from abuse, neglect, and mistreatment and that staff must not permit anyone to engage in verbal, mental, or physical abuse, but the altercation occurred and resulted in physical harm to the first resident.
Failure to Prevent Pressure Ulcers Due to Inadequate Assessment and Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to prevent the development of pressure ulcers in a resident who was at high risk due to severe cognitive impairment, hemiparesis, and dependence on staff for mobility and activities of daily living (ADLs). The resident was admitted without any skin breakdown and was identified as being at risk for pressure ulcers through the Braden Scale and Minimum Data Set assessments. Despite this, the care plan did not include specific interventions such as regular turning and repositioning, use of offloading devices, or strategies to address the resident's tendency to reposition himself onto the affected side. The care plan also lacked updates after the resident began exhibiting behaviors that increased his risk, such as removing pillows used for offloading pressure. The facility's staff did not consistently monitor or document the resident's skin condition as required by policy. There were multiple instances of missing documentation in the ADL Skin Observation Logs across all shifts, and shower sheets were not filed in the resident's chart. Staff interviews confirmed that if documentation was missing, it meant the skin was not checked, which could delay the identification of new or worsening wounds. The facility's policy required CNAs to inspect skin during ADL care and for licensed nurses to document the effectiveness of pressure ulcer prevention techniques, but these steps were not reliably followed. As a result of these failures, the resident developed multiple pressure-related injuries, including dark purple discolorations on the heel and foot, deep tissue pressure injuries, and a Stage III pressure ulcer on the hip. The interdisciplinary team did not convene as required to address the resident's skin breakdowns or revise the care plan to include more effective interventions. The lack of timely assessment, documentation, and care plan updates directly contributed to the resident's skin breakdown and the progression of pressure injuries.
Failure to Prevent Severe Weight Loss Due to Incomplete Nutrition Monitoring and Care Plan Implementation
Penalty
Summary
A deficiency occurred when the facility failed to prevent a resident from experiencing unplanned severe weight loss by not implementing multiple aspects of the resident's care plan and not following the registered dietician's (RD) recommendations. The resident, who had a history of hemiplegia, hemiparesis, protein-calorie malnutrition, and dysphagia, was identified as malnourished and at risk for further nutritional decline. The care plan required staff to monitor and document meal intake percentages for each meal and to offer nutritional supplements if intake was below 50%. However, meal intake was not consistently recorded, and there was no documentation that supplements were provided when intake was low. The RD had recommended providing large-portion meals for the resident on two separate occasions, but these recommendations were not reflected in the physician's orders, nor was there evidence that the recommendations were communicated to or implemented by the physician. Additionally, after significant weight loss was identified, there was no documentation that an interdisciplinary team (IDT) meeting was conducted to address the resident's actual weight loss or to update the care plan accordingly. The facility's policy required notification of the physician and dietician for significant weight changes and updating the care plan, but these steps were not documented as completed. As a result of these failures, the resident experienced severe weight loss over a short period, ultimately requiring transfer to an acute care hospital for further intervention, including the placement of a feeding tube. Interviews with facility staff confirmed that meal intake was not consistently documented, supplements were not always offered as required, and RD recommendations were not followed through with physician orders. The Director of Nursing acknowledged that the facility's policies and procedures for managing resident weights and nutritional care were not followed in this case.
Failure to Maintain a Safe Environment and Provide 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 resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Develop and Implement Immediate Needs Plan Within 48 Hours of Admission
Penalty
Summary
A plan to address a resident's most immediate needs within 48 hours of admission was not created or implemented. This deficiency was identified based on the absence of documentation or evidence that such a plan was developed and put into place for newly admitted residents, as required. The lack of a timely plan meant that the resident's immediate needs upon admission were not formally assessed or addressed within the specified timeframe.
Lack of Staff Training on Dementia Care and Abuse Reporting
Penalty
Summary
Staff did not receive education on dementia care, nor were they trained on the definitions of abuse, neglect, and exploitation, or the procedures for reporting such incidents. This lack of training and education was identified as a deficiency during the survey.
Failure to Replace E-Kits and Document Controlled Substance Disposal
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the replacement of portable container non-antibiotic medication Emergency-Kits (E-Kits) within the stipulated 48-72 hours. During an observation and interview, it was found that two E-Kits with red zip ties, indicating they had been opened, were not replaced in a timely manner. One E-Kit had been opened since February 25, 2025, and the other since December 23, 2024, yet neither had been replaced. The Licensed Vocational Nurse (LVN) acknowledged the importance of having the E-Kit available for emergencies to prevent delays in treatment. The Director of Nursing (DON) confirmed the lack of documentation or monitoring logs to ensure E-Kits were checked daily, which could lead to delays in care during emergencies. The facility also failed to implement its policy on the disposal of medications and medication-related supplies, specifically regarding the destruction of controlled substances. During an inspection, it was revealed that 24 resident medications were disposed of without the required signature of a licensed nurse witnessing the destruction. The DON admitted to being the only licensed nurse responsible for the destruction process and failed to sign the Controlled Drug Record sheets due to being occupied with other tasks. This oversight left the destruction process undocumented, raising concerns about potential diversion and theft of medications. The facility's policy indicated that controlled substances should be securely locked until destroyed by a DEA representative or by the facility's DON and/or consultant pharmacist. However, the DON's failure to follow this procedure and the absence of a second signature on the destruction forms compromised the integrity of the medication disposal process. The lack of adherence to these policies placed residents at risk of not receiving necessary medications during emergencies and increased the potential for loss or diversion of controlled substances.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/7/25, the Director of Nursing had the facility's Emergency kit (E-Kit) replaced. There were no negative or adverse outcomes noted related to this deficient practice. On 3/6/25, the Director of Nursing (DON) presented the facility's Controlled Drug Record dated 12/12/2024 without the signature of a licensed nurse witnessing the destruction of the medications. Medication was destroyed in the presence of the Pharmacist. There were no negative outcomes as a result of this deficient practice. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/7/25, the Infection Control Preventionist conducted a visual round to ensure all E-kits were not expired. No other residents were affected by this deficient practice. On 3/19/25, the Medical Records Director conducted an audit on the past quarter of medication destruction sheets. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/12/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs), on the facility's policy and procedure titled, "Medication Ordering and Receiving from Pharmacy," undated, with emphasis on emergency needs for medication being met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. The in-service included nursing calling the pharmacy as soon as possible for replacement of the kit/dose and flagging the kit with a color-coded lock to indicate need for replacement of kit/dose. The in-service also emphasized that if exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening, and if replacing used medications, the replacement doses are added to the kit within 72 hours of opening. On 3/12/25, the facility created an E-Kit monitoring log and in-serviced Nursing Staff, including but not limited to LVNs and RNs, on how and when to complete it. The DON/designee will conduct audits daily for five days weekly for two weeks, then monthly for three months to ensure E-kits are not expired and logs are completed for monitoring. On 3/17/25, the facility's assigned Pharmacist from Star Pharmacy in-serviced the Director of Nursing (DON) and Registered Nurse (RN) on the facility's policy and procedure titled, "Disposal of Medications and Medication-Related Supplies," with emphasis on controlled substances being retained in a securely locked area with restricted access until destroyed by a Drug Enforcement Administration (DEA) representative or by the facility director of nursing and/or consultant pharmacist and/or administrator. The in-service also included ensuring signatures of licensed nurses witnessing the destruction of the medications. The Medical Records Director will conduct an audit on the medication destruction sheets monthly and as needed (PRN) to ensure signatures include the signature of a licensed nurse witnessing the destruction of the medications. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for the facility's E-kits not being expired for three months or until compliance is met. The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance with medication destruction and disposal, ensuring a signature of a licensed nurse witnessing the destruction of the medications, for three months or until compliance is met.
Failure to Adhere to Professional Standards in Medication Administration and Monitoring
Penalty
Summary
The facility failed to meet professional standards of nursing practice by not properly obtaining accurate orthostatic blood pressure readings for two residents. For Resident 25, the orthostatic blood pressure readings were suspiciously identical on multiple occasions, indicating a potential error in measurement. The Director of Staff Development noted that the readings for both lying and sitting positions were the same on several dates, which is unlikely as there should always be a difference. Similarly, for Resident 1, the orthostatic blood pressure readings were also found to be the same for lying and sitting positions on different dates, and a Licensed Vocational Nurse admitted to not knowing how to properly take these measurements. The facility also failed to ensure that medication was administered to the correct site as ordered by the physician for Resident 96. The resident was supposed to receive Diclofenac Sodium External Gel 1% applied to both knees for pain, but it was instead applied to the right shoulder. The Licensed Vocational Nurse acknowledged the error and admitted to not realizing there was no order for the shoulder application, which could potentially lead to adverse reactions or harm to the resident. Additionally, the facility did not administer Midodrine HCI according to the physician's parameters for Resident 55. The medication was given even when the systolic blood pressure was above the specified limit, and the 10:00 p.m. dose was administered despite instructions not to give it after the evening meal or less than 3-4 hours before bed. The Director of Nursing confirmed that the medication should have been held when the blood pressure was above the limit and that the 10:00 p.m. dose should not have been given, as it could cause potential harm to the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/10/25, License Vocational Nurse (LVN) 4 received one-on-one in-servicing with return demonstration by the Director of Nursing and Director of Staff Development to ensure she understood the definition of orthostatic hypotension and how to perform orthostatic hypotension monitoring. On 3/17/24, Resident 55 started Midodrine HCI 5 mg, give 5 milligrams (mg) orally every 8 hours for hypotension; hold if systolic (top number in a blood pressure reading) blood pressure (SBP) is greater than 110, not to be taken after the evening meal or less than 3-4 hours before bed. Resident 55 was noted to have received medication Midodrine HCI 5 mg outside of parameters. No adverse or negative outcome was noted for Resident 55 as a result of this deficient practice. On 3/10/25, Licensed Vocational Nurse (LVN) 4 received an on-one-one in-service on administering medication per physician order. There were no negative or adverse outcomes for Resident 96 as a result of this deficient practice. On 3/14/25, LVN 4 received an order from Resident 96's Primary Physician for pain medication (Diclofenac Sodium External Gel 1%) to be administered to the left shoulder. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/19/25, the Medical Record Director conducted an audit on residents receiving orthostatic hypotension monitoring to ensure orthostatic hypotension monitoring was being recorded accurately. There was 1 other resident affected by this deficient practice. The residents affected by this deficient practice experienced no negative outcome. On 3/10/25, the Director of Nursing conducted interviews on residents who have topical pain medication orders to ensure residents are receiving topical pain medication as ordered. No other residents were affected by this deficient practice. On 3/24/25, the Medical Records Director conducted an audit on residents with blood pressure medication orders to ensure medication is being administered within parameters ordered by the physician. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/19/25, the Director of Nursing and Director of Staff Development in-serviced Nursing Staff including, but not limited to LVNs and Registered Nurses on the facility's policy and procedure titled, "Blood Pressure, Measuring" with emphasis on orthostatic hypotension being defined as 20 millimeters of mercury (mmHg) decline in systolic blood pressure (the contraction phase of the heart) or a 10 mmHg decline in diastolic blood pressure (relaxing phase of the heart) upon standing and to measure orthostatic hypotension, note the changes in both the systolic and diastolic blood pressure in the standing position compared to the sitting position. The Medical Records Director will conduct an audit on orthostatic hypotension monitoring daily for five days, weekly for two weeks, and monthly thereafter for 3 months to ensure residents' orthostatic hypotension monitoring is being recorded accurately. On 3/21/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to LVNs and RNs, on the facility's policy and procedure titled, "Medication - Administration," with emphasis on testing and taking of vital signs, upon which administration of medications or treatments are conditioned, performing required tests, and recording results. The in-service also included when administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record. The in-service emphasized reviewing the resident's MAR for allergies and/or special considerations for administration, including vital sign parameters and lab results as appropriate. The Medical Records Director will conduct an audit on the following parameters for administering medication for residents with blood pressure medication orders daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' parameters are being followed. On 3/21/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to LVNs and RNs, on the facility's policy and procedure titled, "Medication - Administration," with emphasis on providing professional standards of practice for safe administration of medications for residents in the facility, including following information about any medication they are administering, the drug's route of administration, the drug's indication for use, and desired outcome. The in-service also emphasized the seven "rights" of medication when administering medication: right medication, right amount, right resident, right time, right route, right indication, and right outcome, and the "rule of 3" (performing 3 checks): comparing the physician's order, pharmacy label, and medication administration record (MAR). On 3/31/25, the Director of Nursing/ designee revised orders for residents with pain medication being administered topically to include documentation requirements for where the licensed nurse administered the medication to ensure medication is being administered to the site as ordered. The Medical Records Director will conduct an audit on the following parameters for administering medication for residents with topical pain medication orders daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' parameters are being followed. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for orthostatic hypotension monitoring being monitored accurately, following parameters for administering medication for residents with blood pressure medication orders, and medication administration related to pain medication being administered to the correct site as ordered for three months or until compliance is met.
Deficiencies in Staff Competency and Orthostatic Hypotension Procedures
Penalty
Summary
The facility failed to complete initial and annual skills competencies for four Restorative Nursing Aides (RNAs), which are crucial for maintaining residents' mobility and preventing contractures. During interviews and record reviews, it was revealed that the Director of Staff Development (DSD) acknowledged the absence of these competencies in the employee files of the RNAs. The DSD emphasized the importance of these competencies in ensuring that RNA staff are up-to-date with their skills and can perform their tasks correctly. The Director of Rehabilitation confirmed that no initial or annual skills competencies were completed for the RNA staff, and the Director of Nursing (DON) reiterated the necessity of these competencies for the proper execution of the RNA program. The facility also failed to ensure that a Licensed Vocational Nurse (LVN) understood the purpose and procedure for checking orthostatic hypotension. During interviews, the LVN admitted to not knowing how to take orthostatic blood pressures and not seeking guidance. The DON explained that accurate orthostatic blood pressure readings are essential for managing medication and treatment plans. The facility's policy on measuring blood pressure indicated specific criteria for identifying orthostatic hypotension, which the LVN did not follow. Another LVN also demonstrated a lack of understanding regarding the procedure for obtaining orthostatic blood pressure readings. The LVN incorrectly described the process and purpose of these readings, which was confirmed by the DSD as inaccurate. The facility's policy outlined the correct method for measuring orthostatic hypotension, which involves noting changes in blood pressure from sitting to standing positions. The LVN's failure to follow this procedure resulted in inaccurate documentation of blood pressure readings, as evidenced by identical readings recorded on multiple occasions.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/11/25, the Director of Rehabilitation (DOR) conducted annual competencies for the facility's Restorative Nursing Assistants (RNAs). On 3/10/25, License Vocational Nurse (LVN) 4 and LVN 2 received one-on-one in-servicing with return demonstration by the Director of Staff Development to ensure they understood the definition of orthostatic hypotension and how to perform orthostatic hypotension monitoring. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/17/25, the Director of Staff Development (DSD) conducted an audit on the facility's Restorative Nursing Assistant (RNA) employee files to ensure all Restorative Nursing Assistants had competencies completed. No other residents were affected by this deficient practice. On 3/19/25, the Medical Record Director conducted an audit on residents receiving orthostatic hypotension monitoring to ensure orthostatic hypotension monitoring was being recorded accurately. There was 1 other resident affected by this deficient practice. The resident affected by this deficient practice experienced no negative outcome. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25, the Director of Nursing and Director of Staff Development in-serviced the DOR, Physical Therapist, Occupational Therapist, and Speech Therapist on the facility's policy and procedure titled, "Restorative Nursing Program Guidelines," with emphasis on nursing aides being trained in the techniques that promote resident involvement in the activity. The in-service included completing initial and annual competencies and any training needed when areas of improvement are identified. The Administrator will conduct audits on new hires, RNAs, and current employees who receive new certifications for Restorative Nursing Assistant employee files, to ensure employees have initial competencies as needed. The DSD will conduct audits to ensure RNAs receive their annual competencies when due. On 3/19/25, the Director of Nursing and Director of Staff Development in-serviced Nursing Staff including, but not limited to LVNs and Registered Nurses, on the facility's policy and procedure titled, "Blood Pressure, Measuring," with emphasis on orthostatic hypotension being defined as a 20 millimeters of mercury (mmHg) decline in systolic blood pressure (the contraction phase of the heart) or a 10 mmHg decline in diastolic blood pressure (relaxing phase of the heart) upon standing and to measure orthostatic hypotension, noting the changes in both the systolic and diastolic blood pressure in the standing position compared to the sitting position. The Medical Records Director will conduct an audit on orthostatic hypotension monitoring daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' orthostatic hypotension monitoring is being recorded accurately. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Staff Development will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for RNAs' initial and annual competencies being completed, for three months or until compliance is met. The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for orthostatic hypotension monitoring being monitored accurately, for three months or until compliance is met. The Medical Records Director will conduct an audit on orthostatic hypotension monitoring daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' orthostatic hypotension monitoring is being recorded accurately.
Improper Storage of Insulin and Contaminated Medication Container
Penalty
Summary
The facility failed to properly store medications, specifically insulin, as per the manufacturer's guidelines. During an observation, an unopened Lantus insulin pen, an unopened insulin vial, and an insulin pen of Glargine YFGN were found stored in a medication cart instead of being refrigerated. The Licensed Vocational Nurse (LVN) acknowledged that all insulin should be refrigerated until opened. The Director of Nursing (DON) confirmed that storing unopened insulin outside the refrigerator could decrease its potency and effectiveness, potentially leading to uncontrolled blood sugar levels in residents. The facility's policy indicated that medications requiring refrigeration should be kept in a refrigerator with a thermometer for temperature monitoring. Additionally, a multi-dose medication container of Clear Lax was found soiled and unclean in the medication cart. The LVN identified this as an infection control issue, stating that the medication bottle should always be clean to prevent contamination. The Registered Nurse (RN) and the DON both emphasized the importance of keeping medication containers clean to avoid bacterial contamination, which could make residents sick. The facility's policy stated that contaminated or soiled medication containers should be immediately removed from stock and disposed of according to procedures.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/6/25, Licensed Vocational Nurse (LVN) 4 removed the unopened insulin from the cart. On 3/6/25, LVN 4 re-ordered the insulin. On 3/6/25, LVN 4 removed and discarded the multi-dose bottle of clear lax from the medication cart. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/6/25, the Director of Staff Development (DSD) made visual rounds on the facility’s medication carts to ensure no other unopened insulin was being stored on the cart. No other residents were affected by this deficient practice. On 3/6/25, the DSD conducted visual rounds on the licensed nurse medication carts to ensure multi-dose medications were clean and free from any particles. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/12/25, the Director of Nursing in-serviced nursing staff, including but not limited to LVNs and RNs, on the facility’s policy and procedure titled, "Medication Storage in the Facility; Storage of Medications." On 3/6/25, LVN 4 removed and discarded the multi-dose bottle of clear lax from the medication cart. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/6/25, the DSD made visual rounds on the facility’s medication carts to ensure no other unopened insulin was being stored on the cart. No other residents were affected by this deficient practice. On 3/6/25, the DSD conducted visual rounds on the licensed nurse medication carts to ensure multi-dose medications were clean and free from any particles. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/12/25, the Director of Nursing in-serviced nursing staff, including but not limited to LVNs and RNs, on the facility’s policy and procedure titled, "Medication Storage in the Facility; Storage of Medications," with emphasis on medications and biologicals being stored safely, securely, and properly, following manufacturer’s recommendations or those of the suppliers. This includes medications requiring "refrigeration" or "temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit" being kept in a refrigerator with a thermometer to allow temperature monitoring. The Director of Nursing (DON)/designee will conduct rounds on the facility’s medication carts daily for five days weekly for two weeks and monthly thereafter to ensure an unopened insulin is not being stored in the medication cart. On 3/12/25, the DON conducted an in-serviced nursing staff, including but not limited to LVNs and RNs, on the facility’s policy and procedure titled, "Medication Storage in the Facility; Storage of Medications," with emphasis on outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures. These should be immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy. The Director of Nursing/designee will conduct rounds daily for 5 days weekly for 2 weeks and monthly thereafter to ensure multi-dose medications are clean and free from particles. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for proper storage of insulin and multi-dose medication being clean and free from particles for three months or until compliance is met.
Failure to Implement Laboratory Orders for Residents
Penalty
Summary
The facility failed to implement laboratory orders for three residents, leading to delays in care and potential health risks. Resident 25, who was admitted with acute kidney failure, anemia, severe obesity, and Type 2 diabetes, did not have a complete blood count (CBC), complete metabolic panel (CMP), and Hemoglobin A1C (Hgb A1C) drawn as ordered every three months. This oversight was confirmed during a review of the resident's records and an interview with a Licensed Vocational Nurse (LVN), who acknowledged that the tests were not conducted in February, preventing the physician from identifying any potential issues with the resident's blood work. Similarly, Resident 42, who was admitted with Vitamin D deficiency, hyperlipidemia, and gastro-esophageal reflux disease, did not have a CMP conducted in September and December as ordered. The resident's care plan emphasized the importance of obtaining and monitoring laboratory work to prevent poor food intake, weight loss, and dehydration. During an interview, the LVN confirmed that the CMP was not done, which could have prevented the doctor from detecting any abnormal results. Resident 100, diagnosed with respiratory failure, epilepsy, and polycystic kidney disease, was supposed to have monthly Keppra level blood draws to monitor therapeutic levels and prevent seizures. However, the last recorded draw was in November, with subsequent months missed. A Registered Nurse (RN) confirmed the oversight, acknowledging that the lack of blood draws could worsen the resident's epilepsy disorder. The facility's policy and procedure indicated the responsibility for ensuring timely laboratory services, which was not adhered to in these cases.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Resident 25 and Resident 42 labs were drawn. The Primary Physician was made aware of the results with no new orders noted. On 3/12/25, Resident 100 labs were drawn. The Primary Physician was made aware of the results with no new orders noted. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/13/25, the Medical Records Director conducted an audit on active resident lab orders to ensure all residents are receiving their labs as ordered, unless otherwise refused. There were 2 residents affected by this deficient practice. On 3/15/25, the Director of Nursing/designee re-ordered the missing labs for those affected residents. There were no negative or adverse outcomes to this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 3/26/25, the Director of Nursing (DON) in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs), on the facility's policy and procedure titled, "Laboratory, Diagnostic and Radiology Services," with emphasis on laboratory, diagnostic, and radiology services being provided to meet resident needs and the facility being responsible for the quality and timeliness of services provided by the laboratory. The in-service also included that laboratory services ordered are documented on the 24-hour report or electronic health record, to ensure that services are coordinated, and results are received, with notification of results to the Primary Physician including any refusals. The Medical Records Director will audit residents' lab orders daily for five days weekly for two weeks and monthly thereafter to ensure residents are receiving lab draws as ordered, unless otherwise noted by a refusal. There were 2 residents affected by this deficient practice. On 3/15/25, the Director of Nursing/designee re-ordered the missing labs for those affected residents. There were no negative or adverse outcomes to this deficient practice. The measures to prevent recurrence include the same in-service training and ongoing audits as described above. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for providing laboratory services as ordered for three months or until compliance is met.
Improper Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage practices in the kitchen, as observed during a survey. Specifically, three bags of dry cereal were found with plastic wrap tied loosely around them, leaving the bags open and susceptible to pest entry and contamination. Additionally, an opened gallon of pancake mix and waffle syrup were observed without labels indicating the date they were opened. During an interview, the Dietary Aide acknowledged that the improperly tied cereal bags could allow pests to contaminate the food and that the pancake mix and syrup should have been labeled with the opened date to prevent serving expired products to residents. The Dietary Service Supervisor confirmed that the facility's policy required opened products to be stored in containers with tight-fitting lids and labeled with the date of opening.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25, the Dietary Manager discarded the three bags of dry cereal that were loosely tied with plastic wrap, the open gallon of pancake mix, and the open gallon of waffle syrup that did not have a label indicating the date it was opened. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/4/25, the Administrator conducted visual rounds throughout the facility's kitchen to ensure that all items that were opened were properly stored in containers with tight fitted lids or sealed tightly, and labeled with open dates. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25, the Dietary Manager in-serviced Dietary Staff, including but not limited to, dietary cooks and aids, on the facility's policy and procedure titled, "Food Storage" with emphasis on opened products being placed in storage containers with tight fitting lids and storage products being labeled and dated. The Administrator will conduct rounds in the facility's kitchen daily for five days, weekly for two weeks, and monthly thereafter to ensure products are being properly stored in tight, fitted containers or sealed tightly and labeled and dated. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for food storage, including being properly labeled and dated for three months or until compliance is met.
Facility Lacks Contingency Plan in Assessment
Penalty
Summary
The facility failed to ensure a contingency plan was developed and included in the Facility Assessment, which is necessary for identifying the resources needed to provide care and services during both regular operations and emergencies. During an interview and record review, the Administrator acknowledged that the Facility's Assessment was incomplete and did not include a contingency plan addressing staffing needs during emergencies that could affect resident care. The Administrator noted that the Facility Assessment should provide an overview of the resident population and reflect the services provided by the facility, including identifying risks and ensuring the facility can operate fully without delay during unforeseeable events. The facility's undated policy and procedure titled 'Facility Assessment' indicated that the assessment should inform contingency planning for events that do not require activation of the facility's emergency plan but could still impact resident care, such as the availability of direct care nurse staffing. Additionally, a review of CMS guidance clarified that facilities must conduct and document a facility-wide assessment to determine necessary resources for competent resident care during both day-to-day operations and emergencies. The lack of a contingency plan in the Facility Assessment had the potential to hinder the facility's ability to respond effectively during unexpected circumstances, potentially impacting resident care.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/12/25, the Administrator held a meeting that included the Medical Director, the Director of Nursing, Social Services Director, Activities Director, a Registered Nurse Supervisor, a License Vocational Nurse, two Certified Nursing Assistants to revise the facility's facility assessment to include a contingency plan. The contingency plan included having a pool of on-call staff to assist in providing additional staff needed in a case of events that does not require the facility to activate its emergency plan. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/14/25, the Administrator reviewed the facility's reported incidents to identify any events that required the facility to activate its facility assessment related to the contingency plan. There were no facility reported incidents that required an activation of the facility assessment's contingency plan. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Director of Nursing and Director of Staff Development in-serviced the Administrator on the facility's policy and procedure titled, "Facility Assessment," with emphasis on the facility using the Facility Assessment to inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to the availability of direct care nurse staffing or other resources needed for resident care. The in-service also included the "Revised Guidance for Long-Term Care Facility Assessment Requirements" with emphasis on conducting and documenting a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations including nights and weekends and emergencies. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for the facility assessment having a contingency plan for three months or until compliance is met.
Lack of QAPI Documentation for Repeat Deficiencies
Penalty
Summary
The facility failed to provide meeting minutes or evidence of Quality Assurance and Performance Improvement (QAPI) program efforts to address three repeat deficiencies in Resident Rights, Laboratory Services, and Pharmacy Services. These deficiencies were previously identified during a recertification survey conducted by the California Department of Public Health (CDPH) in 2024. During an interview, the Administrator acknowledged the absence of documentation and emphasized the importance of discussing and developing a QAPI program to address these deficiencies. The lack of documentation indicated that the facility did not effectively investigate, analyze, or implement corrective actions to improve performance in these areas. A review of the facility's undated policy and procedure (P&P) titled QAPI Plan revealed that the QAPI Steering committee is responsible for analyzing performance and identifying areas for improvement. The P&P also stated that meeting minutes should be recorded and shared with the QAPI Steering committee, executive leadership, and staff. However, the facility did not adhere to these guidelines, as evidenced by the absence of meeting minutes or any documentation of QAPI activities related to the identified deficiencies. This lack of documentation and follow-up placed residents at risk for harm if the areas identified were not adequately addressed.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/24/25, the Quality Assurance (QA) Nurse reviewed the facility's "Statement of Deficiencies (SOD)," dated 3/8/2024, related to Resident Rights, Laboratory Services, and Pharmacy Services. On 3/24/25, the QA Nurse developed a Quality Assurance and Performance Improvement (QAPI) plan for the current deficiencies. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/19/25, the Medical Records Director conducted an audit on the facility's Statement of Deficiencies, dated 3/8/24, to ensure each deficient practice noted had a QAPI developed with a root cause, interventions, goals, and how the facility would monitor and audit the program. There was 1 deficiency without a developed QAPI plan. On 3/24/25, the Administrator and QA Nurse developed a QAPI from the facility's previous deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Administrator in-serviced the QA Nurse on the facility's policy and procedure, titled "QAPI Plan," with emphasis on the QAPI Steering committee analyzing performance to identify and follow up on areas of opportunity, with meeting minutes being recorded and shared with the QAPI Steering committee, executive leadership, and staff. The in-service emphasized the facility continually identifying opportunities for improvement and using the criteria to prioritize opportunities such as aspects of care affecting large numbers of residents, regulatory requirements, SOD from complaint visits, and surveys. The in-service also included ensuring the facility's QAPI plans include a root cause, interventions, goals, and how the facility would monitor and audit the program. The Administrator will conduct monthly and as-needed (PRN) audits on the facility's QAPI plans to ensure facility-identified problems or deficient practices on a Statement of Deficiencies are QAPI and maintained. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for the facility developing a Quality Assurance and Performance Improvement plan for deficient practices for three months or until compliance is met.
Improper Storage of Wheelchairs and Geriatric Chair
Penalty
Summary
The facility failed to ensure that five wheelchairs and one geriatric chair were stored properly, as they were found outside under the rain. This practice had the potential to damage the medical equipment and prevent their safe use for residents. During an interview, the Director of Rehabilitation (DOR) mentioned difficulties in maintaining and keeping track of wheelchairs, as they often get lost. The DOR also noted that a wheelchair prepared for a resident was stored outside in the rain, rendering it unusable for the day due to its wet condition. The resident required a custom wheelchair, and no alternative was available. Further observations revealed that four wheelchairs and one geriatric chair were left in an outdoor area exposed to the elements. The Maintenance Supervisor acknowledged that the covered shed was full and primarily used for activity equipment, leaving no covered storage space for the medical equipment. The Director of Nursing confirmed that wheelchairs and other medical equipment should not be stored outside in uncovered areas. Additionally, the Medical Records Supervisor stated that the facility lacked a policy regarding the storage of medical equipment.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25 the Maintenance Director and Maintenance Assistant removed all wheelchairs and geriatric chairs from the patio. On 3/5/25, the facility began storing all wheelchairs and geriatric chairs inside the facility in the newly designated area. How do facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/5/25, the Administrator and Maintenance Director made visual rounds on the outdoor areas of the facility to ensure medical equipment is not being stored in uncovered areas. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/27/25, The Director of Staff Development in-serviced Vocational Nurses (LVN), and Certified Nursing Assistants (CNA), along with the Maintenance Department and Housekeeping Department were in-serviced on having and maintaining proper covered storage for resident equipment. The Maintenance Director/designee will conduct rounds on the facility outside areas daily for 5 days weekly for 2 weeks and monthly thereafter to ensure resident equipment is not being stored in non-covered areas. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for proper storage of resident equipment for three months or until compliance is met.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their responsible party was informed in advance of the risks and benefits of psychoactive medication. This deficiency was identified for one resident who was receiving Seroquel and Duloxetine HCI. The resident, who had a history of diabetes mellitus, chronic kidney disease, and bipolar disorder, was assessed to have the capacity to understand and make decisions. Despite this, there was no informed consent documented in the resident's chart for the administration of these medications. Interviews with facility staff, including a registered nurse, the assistant director of nursing, and the director of nursing, confirmed that informed consent should have been obtained and documented before administering the medications. The facility's policies and procedures also required informed consent to be documented in the resident's medical record. The absence of informed consent documentation meant that the resident might have been administered medication without being fully informed or having the opportunity to decline it.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/7/25, the Minimum Data Set Nurse (MDSN) Assistant clarified Resident 46 psychotropic medication and received informed consent from Resident 46 to administer Seroquel and Duloxetine psychotropic medication. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/11/25, the Medical Records Director conducted an audit on all active residents' psychotropic medications to ensure psychotropic informed consents were completed. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to License Vocational Nurses and Registered Nurses, on the facility's policy and procedure titled, "Informed Consent," with emphasis on ensuring the facility respects the resident's right to make an informed decision prior to deciding to undergo certain medical therapies and procedures. The in-service also included ensuring the informed consent/notice be documented, and placed in the resident's medical record for verification that consent/notice was given. On 3/10/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to License Vocational Nurses and Registered Nurses, on the facility's policy and procedure titled, "Psychotherapeutic Drug Management," with emphasis on obtaining consent for use of psychotherapeutic drugs, informing the resident of the risks and benefits for the use of these medications, and ensuring the consent remains in place until medication is discontinued or until consent is revoked by the resident/responsible party. The Medical Records Director will conduct audits on psychotropic consent forms daily for 5 days, weekly for 2 weeks, and monthly thereafter to ensure residents have received informed consent prior to the administration of psychotropic medication. How the facility plans to monitor its performance to make sure that solutions are maintained: The Social Service Director will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for receiving informed consent prior to the administration of psychotropic medication for three months or until compliance is met.
Resident Excluded from Care Planning Meetings
Penalty
Summary
The facility failed to ensure that Resident 275 participated in care planning meetings, which is a violation of the resident's rights. Resident 275, who has a medical history of chronic obstructive pulmonary disease, hypertension, and congestive heart failure, was admitted to the facility and was capable of understanding and making medical decisions. Despite this, the resident was not invited to attend care plan meetings, as confirmed by both the resident and the Director of Nursing (DON). The DON acknowledged that it was the responsibility of the nursing or social service staff to notify and invite the resident to these meetings. The facility's policy and procedure on care planning, dated 10/24/2022, states that residents should be invited to care planning meetings if they are capable, and efforts should be made to schedule these meetings at convenient times for the resident and their family. Additionally, the facility's policy on resident rights, dated 5/1/2023, emphasizes the resident's right to be fully informed and participate in their treatment. The failure to include Resident 275 in the care planning process was identified as a deficiency by the surveyors.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/11/25, the Interdisciplinary Team (IDT) met with Resident 275 and conducted a care conference meeting. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/20/25, the Medical Records Director conducted an audit on all new admissions and re-admissions within the last 30 days to ensure residents had attended their baseline care conference meeting. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/18/25, the Director of Nursing and Director of Staff Development in-serviced the Interdisciplinary Team (IDT), including but not limited to Minimum Data Set Nurse and Assistant, Social Services Director and Assistant, Director of Rehabilitation (DOR), Activities Director, and Dietary Manager on the facility's policy and procedure titled, "Care Planning" with emphasis on inviting the resident, if capable, and their family to the care planning meetings and scheduling the care planning meetings at the time of convenience for the resident and family. On 3/18/25, the Director of Nursing and Director of Staff Development in-serviced the IDT, including but not limited to Minimum Data Set Nurse and Assistant, Social Services Director and Assistant, DOR, Activities Director, and Dietary Manager on the facility's policy and procedure titled, "Resident's Rights" with emphasis on the resident having the right to be fully informed and participate in their treatment in a language that they can understand. The Medical Records Director will conduct an audit daily for 5 days, weekly for 2 weeks, and monthly thereafter on all new admissions and re-admissions to ensure baseline care plans are scheduled and the resident and/or resident representative are included in the development of the care plan. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for residents' rights to attend and participate in care plan meetings for three months or until compliance is met.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which is a critical component for residents to communicate their needs to the nursing staff. Resident 36, who was admitted with chronic obstructive pulmonary disease, hemiplegia, and muscle weakness, was observed with the call light on the floor behind the bed, out of reach. This was confirmed by a Certified Nursing Assistant (CNA) who acknowledged the protocol to keep the call light within reach to prevent falls and ensure timely assistance. The Registered Nurse (RN) also confirmed that the call light should be near the resident to avoid delays in service and care. Similarly, Resident 224, who had difficulty walking, muscle weakness, asthma, and congestive heart failure, was found with the call light device behind the bed on the floor, not within reach. The CNA and Licensed Vocational Nurse (LVN) both stated that the call light should be accessible to the resident for safety and to alert staff in emergencies. The Director of Nursing (DON) reiterated the importance of having the call light within reach to meet the resident's needs promptly. The facility's policy and procedure on the call system also indicated that call cords should be placed within the resident's reach to enable prompt communication with nursing staff.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25, Certified Nursing Assistant (CNA) 3 removed the call light from the floor and placed it within reach of resident 36. On 3/4/25, Certified Nursing Assistant (CNA) 5 removed the call light from behind resident 224's bed and placed it within reach of resident 224. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/4/25, Department Managers, including but not limited to the Administrator, Director of Nursing, Director of Staff Development (DSD), Social Services Director, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, Minimum Data Set (MDS) Coordinator and Assistant, and Quality Assurance (QA) Nurse conducted visual rounds to ensure no other resident call light was not within reach. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/13/25, the Director of Nursing and Director of Staff Development in-serviced facility staff, including but not limited to Certified Nursing Assistants, Licensed Vocational Nurses, and Registered Nurses, and Department Managers on the facility's policy and procedure titled "Communication-Call System" with emphasis on the facility providing a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities and promptly communicate their needs. The in-service also included placing the call cords within the residents' reach. Department Managers, including but not limited to the DSD, Social Services Director and Assistant, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, MDS Coordinator and Assistant, and QA Nurse, will conduct room rounds daily for 5 days, weekly for 2 weeks, and monthly thereafter to ensure residents' call lights are in reach. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/4/25, Department Managers, including but not limited to the Administrator, Director of Nursing, Director of Staff Development (DSD), Social Services Director, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, Minimum Data Set (MDS) Coordinator and Assistant, and Quality Assurance (QA) Nurse conducted visual rounds to ensure no other resident call light was not within reach. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/13/25, the Director of Nursing and Director of Staff Development in-serviced facility staff, including but not limited to Certified Nursing Assistants, Licensed Vocational Nurses, and Registered Nurses, and Department Managers on the facility's policy and procedure titled "Communication-Call System" with emphasis on the facility providing a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities and promptly communicate their needs. The in-service also included placing the call cords within the residents' reach. Department Managers, including but not limited to the DSD, Social Services Director and Assistant, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, MDS Coordinator and Assistant, and QA Nurse, will conduct room rounds daily for 5 days, weekly for 2 weeks, and monthly thereafter to ensure residents' call lights are in reach. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will review the Department Manager room rounds and will report to the Quality Assurance and Improvement Committee during its monthly meeting the status of the compliance for call lights being in reach for three months or until compliance is met.
Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility failed to honor a resident's preference for a shower, which was a violation of the resident's right to self-determination. Resident 273, who was admitted with conditions including urinary retention, dysphagia, and a urinary tract infection, expressed a desire for showers instead of bed baths. Despite having the cognitive ability to make decisions and requiring only moderate assistance with personal hygiene, the resident's request for showers was not fulfilled. The facility's shower schedule indicated that the resident was to receive showers on Mondays and Thursdays, but the resident reported not having received a shower since admission. Interviews with staff revealed that there was no valid reason for denying the resident's request for a shower. A CNA confirmed that the resident had approval from the Physical Therapist to have showers, and the Director of Rehab stated that the resident required minimal assistance with transfers and was capable of standing and walking. The facility's policy stated that residents should be offered showers at least once a week and according to their requests, and the resident rights policy emphasized the importance of honoring residents' choices regarding personal care. The failure to provide the requested showers had the potential to affect the resident's psychosocial well-being, as noted by the Director of Staff Development.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25 Resident 273 was given a shower by assigned CNA. Social Services Director followed up with resident 273 in regards to receiving a shower. Resident 273 expressed no further adverse reaction or negative outcome from not receiving a shower. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/18/25 Social Services Director and Social Services Assistant conducted resident interviews to ensure residents are receiving a shower. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25 the Director of Staff Development (DSD) in-serviced Nursing Staff, including but not limited to License Vocational Nurse, Registered Nurses, Certified Nursing Assistants (CNA), and Restorative Nursing Assistants (RNA) on the facilities policy and procedure titled, "Showering a Resident" with emphasis on ensuring residents are offered a shower at a minimum of once weekly and given per resident request. On 3/11/25, the DSD in-serviced Nursing Staff, including but not limited to LVNs, RNs, CNAs, and RNAs on the facilities policy and procedure titled, "Resident Rights," with emphasis on residents being allowed to choose activities, schedules and health care that are consistent with their interest, assessments and plan of care including personal care needs such as bathing methods and grooming styles. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/18/25 Social Services Director and Social Services Assistant conducted resident interviews to ensure residents are receiving a shower. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25 the Director of Staff Development (DSD) in-serviced Nursing Staff, including but not limited to LVNs, RNs, CNAs, and RNAs on the facilities policy and procedure titled, "Showering a Resident" with emphasis on ensuring residents are offered a shower at a minimum of once weekly and given per resident request. On 3/11/25, the DSD in-serviced Nursing Staff, including but not limited to LVNs, RNs, CNAs, and RNAs on the facilities policy and procedure titled, "Resident Rights," with emphasis on residents being allowed to choose activities, schedules and health care that are consistent with their interest, assessments and plan of care including personal care needs such as bathing methods and grooming styles. Department Managers will conduct rounds daily for five days weekly for two weeks and monthly thereafter to ensure residents are receiving a shower as scheduled. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will review the Department Manager rounds and will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for showers given to residents for three months or until compliance is met.
Failure to Timely Provide NOMNC Form
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form to the representative of a resident, identified as Resident 32, within the required timeframe. Resident 32 was admitted with diagnoses including unspecified dementia, cerebrovascular accident, and dysphagia. The Minimum Data Set (MDS) assessment indicated that Resident 32 had moderately impaired cognitive skills and required assistance with daily activities. The Business Office Manager (BOM) acknowledged that the NOMNC form was given to the resident's representative only one day before the end of Medicare Part A skilled services, instead of the required 48 to 72 hours prior. The facility's policy, titled Medicare Denial Process, mandates that the NOMNC form be delivered at least two calendar days before the end of Medicare-covered services. However, the BOM admitted that the form was provided late, which deprived the resident's representative of the opportunity to appeal the decision regarding financial coverage for continued skilled care services. This oversight had the potential to result in the resident unknowingly incurring expenses for non-covered care.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/10/25 the Business Office Manager (BOM) contacted the responsible party for Resident 52 and issued the Notice of Medicare Non-Coverage (NOMNC) with the correct dates of the last covered day and first non-covered day for Resident 52. Resident 52's responsible party verbalized understanding and did not have any further questions or concerns at that time. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/10/25 the Administrator conducted an audit of active residents who received a NOMNC within the last six months. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25 the Administrator in-serviced the Business Office Manager on the facility's policy and procedure titled, "Medicare Denial Process," with emphasis on delivering the NOMNC at least two calendar days before Medicare covered services end or the second to last day of services if care is not being provided daily as referenced in the NOMNC instructions (CMS-10123). The Administrator will conduct audits on residents who are receiving NOMNCs daily for 5 days, weekly for 2 weeks, and monthly thereafter to ensure that NOMNCs are being provided at least two calendar days before Medicare coverage services end or the second to last day of services if care is not being provided daily. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for NOMNC given to residents for three months or until compliance is met.
Late Submission of MDS Assessment
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) for a resident within the required 14-day period after the assessment was completed. The resident, who was admitted with diagnoses including diabetes mellitus, cerebrovascular accident, and anemia, had an MDS assessment dated 10/21/2024. This assessment indicated that the resident was independent in cognitive skills for daily decision-making but totally dependent on staff for eating, oral hygiene, and personal hygiene. However, the MDS was not submitted to the Centers for Medicare and Medicaid Services (CMS) until 11/21/2024, which was beyond the 14-day submission requirement. During an interview and record review, the Minimum Data Set Nurse (MDSN) confirmed that the MDS assessment was submitted late and acknowledged the importance of timely submission to comply with regulations. The facility's policy, dated 1/2018, mandates that resident assessments be conducted and submitted in accordance with federal and state timeframes. The delay in submission resulted in incorrect data being transmitted to CMS, potentially affecting the continuity of care for the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, the Minimum Data Set Nurse (MDSN) reviewed Resident 93's Minimum Data Set (MDS) assessment, dated 10/21/2024. MDSN noted Resident 93's MDS Assessment Reference date was 10/21/2024 and had been submitted late to the CMS on 11/21/2024. There were no negative outcomes related to this deficient practice for Resident 93, who discharged home on 11/7/24. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/19/25, the Medical Records Director conducted an audit on the past quarter's MDS submissions. There were 2 residents affected by this deficient practice. There were no negative outcomes noted for residents affected. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/18/25, the facility Consultant and Administrator in-serviced the Director of Nursing, MDSN, and MDSN Assistant on the facility's policy and procedure titled, "MDS Completion and Submission Timeframes," with emphasis on the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes, including but not limited to submitting MDS assessments within 14 days after the completion to the Centers of Medicare and Medicaid Services (CMS). The Medical Records Director will conduct an audit on MDS assessments daily for five days weekly for two weeks and monthly thereafter to ensure MDS assessments were transmitted to CMS within 14 days after completion. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for submitting MDS assessments to CMS within 14 days after completion for three months or until compliance is met.
Failure to Develop Care Plan for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement a care plan for a resident receiving Seroquel and Duloxetine, which are psychotropic medications. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted to the facility with diagnoses including diabetes mellitus, chronic kidney disease, and bipolar disorder, was assessed to have clear comprehension and the capacity to make decisions. Despite this, there was no care plan in place for the administration of these medications, as confirmed by a registered nurse during a record review. Interviews with the Minimum Data Set Nurse and the Director of Nursing revealed that care plans are essential for providing individualized care and ensuring that residents' needs are met. The facility's policy and procedure documents also indicated that a comprehensive, person-centered care plan should be developed for each resident, including those receiving psychotropic medications. The absence of a care plan for the resident's psychotropic medication use was acknowledged by the staff, highlighting a lapse in the facility's adherence to its own policies and procedures.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/7/25, the Minimum Data Set Nurse (MDSN) Assistant care planned the psychotropic medication, Seroquel and Duloxtine, for Resident 46. The care plan included the use of the psychotropic medication being a risk, the goal that Resident 46 will remain free of psychotropic drug-related complications, and the interventions including, but not limited to, providing a safe and calm environment, monitoring for side effects of the use of psychotropics, and encouraging activities of preference. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/11/25, the Medical Records Director conducted an audit on care plans for psychotropic medications, including, but not limited to, Seroquel and Duloxetine. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Director of Nursing in-serviced Licensed Nurses, including but not limited to Licensed Vocational Nurses, including MDSN Supervisor and Assistant, and Registered Nurses on the facility's policy and procedure titled, "Care Planning," with emphasis on a comprehensive person-centered care plan being developed for each resident based on their individual assessed needs, which includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs. On 3/10/25, the Director of Nursing in-serviced Licensed Nurses, including but not limited to Licensed Vocational Nurses, including MDSN Supervisor and Assistant, and Registered Nurses on the facility's policy and procedure titled, "Psychotherapeutic Drug Management," with emphasis on nursing responsibility to implement and update the care plan as indicated. The in-service also included not administering psychotherapeutic medication until an informed consent has been obtained and documented by the Attending Physician/LHP (Licensed Healthcare Professional) from the resident and/or surrogate decision maker. The Medical Records Director will conduct an audit daily for 5 days, weekly for 2 weeks, and monthly thereafter on psychotropic medication being care planned. How the facility plans to monitor its performance to make sure that solutions are maintained: The Social Services Director will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for care planning psychotropic medication use for three months or until compliance is met.
Failure to Provide Necessary Equipment for Resident Mobility
Penalty
Summary
The facility failed to provide a resident, identified as Resident 104, with the necessary care and services to perform activities of daily living, specifically by not providing an appropriate wheelchair for transfers and out-of-bed activities. Resident 104 was readmitted to the facility with diagnoses including muscle weakness and lack of coordination. Despite having the capacity to understand and make decisions, the resident was noted to have severe cognitive impairment and functional limitations in both upper and lower extremities, requiring dependent assistance for bed-to-chair transfers. The care plan for Resident 104 indicated a need for necessary equipment to improve functional abilities, yet no wheelchair was provided. Observations and interviews revealed that Resident 104 had been asking for a wheelchair since admission but had not received one, preventing participation in activities and going outside. The Director of Rehabilitation acknowledged the importance of providing proper equipment like a wheelchair to prevent muscle atrophy and promote environmental stimulation. However, the process of assessing and providing a wheelchair was delayed, with the Director admitting that the facility should have initiated this process upon the resident's admission. Further interviews with staff, including a CNA and LVN, highlighted a lack of encouragement for the resident to get out of bed, which is crucial for preventing health issues such as pneumonia. The Director of Nursing emphasized the importance of residents getting out of bed for mental and physical health benefits. It was also noted that the facility lacked a policy and procedure for providing wheelchairs and equipment, contributing to the deficiency in care for Resident 104.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/6/25 Resident 104 was provided with a wheelchair. On 3/6/25, the Director of Rehabilitation (DOR) offered Resident 104 to get out of bed with the provided wheelchair; however, Resident 104 refused to get out of bed. On 3/7/25, the DOR offered Resident 104 to get out of bed with the provided wheelchair; however, Resident 104 refused to get out of bed. On 3/21/25, Resident 104 was offered to get out of bed by the DOR; however, Resident 104 refused. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/10/25, the DOR conducted an audit to ensure all residents who can have a wheelchair have a wheelchair. Wheelchair tags were provided for each resident to identify their wheelchair. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25, the DOR in-serviced the Therapy Department on assessing and providing a resident with a wheelchair. The DOR/designee will evaluate new admissions and re-admissions on their functional ability to use a wheelchair. The DOR/designee will then provide the new admission or re-admission with the appropriate wheelchair. The Medical Records Director will audit daily for 5 days weekly for 2 weeks and monthly thereafter to ensure new admissions and re-admissions have been provided a wheelchair if applicable. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for providing residents with a wheelchair for three months or until compliance is met.
Failure to Provide Adequate Activities for Resident
Penalty
Summary
The facility failed to provide adequate activities for one of the sampled residents, Resident 24, outside of her room, leading to feelings of isolation and lack of socialization. Resident 24, who was admitted with conditions including hemiplegia, hemiparesis, and epilepsy, expressed a desire to participate in group activities and go outside for fresh air. Her Minimum Data Set (MDS) indicated that it was very important for her to engage in group activities and enjoy outdoor time when the weather permitted. Despite this, the resident reported that she only left her room when housekeeping performed deep cleaning, and the Activities Director (AD) confirmed that activities were primarily conducted one-on-one in her room. The AD noted that Resident 24 often declined invitations to join group activities, but the Director of Rehabilitation (DOR) acknowledged that the resident had expressed a desire to leave her room and the building. A custom wheelchair was ordered to facilitate her safe and comfortable participation in activities outside her room. The facility's policy on activities, revised in 2021, stated that the program should meet the needs, interests, and preferences of residents, which was not adequately fulfilled in this case, as Resident 24's care plan required a variety of activity types and locations to maintain her interests.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Resident 24 was offered to attend group activities on the following day (3/6/25). On 3/6/25, Resident 24 attended group activities including but not limited to coffee chat, morning warm-up, daily chronicle, bowling, Soul Train, and a movie with popcorn. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/18/24, the Social Services Director (SSD) and Social Services Assistant (SSA) conducted resident interviews regarding group activity participation. Residents who verbalize a desire to participate in group activities responded to the survey that they do attend group activities. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/18/25, the Director of Nursing and Director of Staff Development (DSD) in-serviced the Activities Department and Certified Nursing Assistants on the facility's policy and procedure titled "Activities Program" with emphasis on the facility providing an activity program designed to meet the needs, interests, and preferences of the residents and ensuring residents who express the desire for a particular activity, for example, group activities, be assisted in participation. Department Managers will conduct room rounds daily for five days weekly for two weeks and monthly thereafter to ensure residents who have the desire to participate in group activities are assisted with attending group activities. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for assisting residents with participation in group activities for three months or until compliance is met. What systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/18/25, the Director of Nursing and Director of Staff Development (DSD) in-serviced the Activities Department and Certified Nursing Assistants on the facility's policy and procedure titled "Activities Program" with emphasis on the facility providing an activity program designed to meet the needs, interests, and preferences of the residents and ensuring residents who express the desire for a particular activity, for example, group activities, be assisted in participation. Department Managers will conduct room rounds daily for five days weekly for two weeks and monthly thereafter to ensure residents who have the desire to participate in group activities are assisted with attending group activities. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for assisting residents with participation in group activities for three months or until compliance is met.
Failure to Prevent Decline in Joint Range of Motion
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM) for two residents with limited ROM. Resident 3 did not receive timely quarterly Rehabilitation Joint Mobility Assessments (JMA) to monitor changes in joint ROM. The Director of Rehabilitation acknowledged that the last JMA for Resident 3 was completed on 11/20/2024, and another was due by February 2024, which was not completed. This delay in assessment could hinder the early detection of contractures, which are crucial to prevent further decline in ROM. Resident 27 was supposed to have a left elbow extension splint placed five days a week, as per physician orders. However, the Medication Administration Record (MAR) indicated that the splint was not placed on several occasions in February and March 2025. Both the Restorative Nurse Assistant and a Registered Nurse confirmed the absence of documentation for the splint application on these dates, which could lead to a decline in the resident's left elbow condition. The facility's policies and procedures require staff to identify the resident's current ROM and ensure the application of splints to prevent contractures. The failure to adhere to these policies for both residents could potentially lead to further decline in their joint mobility and overall quality of life.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, the Director of Rehabilitation (DOR) completed Resident 3's joint mobility assessment. Based on the assessment, Resident 3 did not experience any negative outcome or adverse reaction in functional ability as a result of this deficient practice. On 3/7/25, Resident 27's order was clarified to allow the Restorative Nursing Assistant (RNA) to provide the extension splint as ordered. From 3/7/25 to 3/15/25, Resident 27 was provided her extension splint on 3/8/25, 3/11/25, 3/12/25, 3/13/25, 3/14/25, and 3/15/25. On 3/18/25, Resident 27 was transferred to the hospital for unrelated reasons. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/5/25, the DOR/designee conducted an audit on all active residents for quarterly joint mobility assessments. No other residents were affected by this deficient practice. On 3/13/25, the Medical Records Director conducted an audit on all active residents who have splint orders and compared it to the restorative nursing assistant documentation. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 3/10/25, the DOR in-serviced the Therapy Department on the facility's policy and procedure titled, "Resident Mobility and Range of Motion," with emphasis on staff identifying the resident's current ROM of his or her joints as part of the resident's assessment. The in-service also included completing joint mobility assessments on admission or re-admission and quarterly thereafter. The Medical Records Director will audit daily for 5 days weekly for 2 weeks and monthly thereafter to ensure that the therapy department is completing joint mobility assessments on a quarterly basis. On 3/13/25, the Director of Rehabilitation in-serviced RNs on the facility policy and procedure titled, "Splinting," with emphasis on preventing contractures or decreased tone and protecting joint alignment. The in-service also emphasized RNAs being responsible for applying the splint as ordered, documentation, and initialing on the schedule for splint application each time splint is applied, removed, or refused. The Medical Records Director will audit daily for five days weekly for two weeks and monthly thereafter to ensure that splint orders and RNA documentation are maintained, confirming residents are receiving their splints as ordered and that refusals are documented. How the facility plans to monitor its performance to ensure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting on the status of compliance regarding the therapy department completing quarterly joint mobility assessments and providing residents with splints as ordered for three months or until compliance is met.
Improper Positioning During Enteral Feeding
Penalty
Summary
The facility failed to ensure the proper positioning of the head of the bed (HOB) for a resident receiving enteral tube feeding, which is necessary to reduce the risk of aspiration. During an observation, it was noted that the resident was lying flat on their back while the tube feeding was running, contrary to the facility's policy that requires the HOB to be elevated at least 30 degrees during feeding. This oversight was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged that the HOB should be elevated between 30 to 45 degrees to prevent aspiration and potential aspiration pneumonia. The resident involved had a history of gastro-esophageal reflux disease, dysphagia, and a gastrostomy, and was dependent on staff for personal care. The resident's cognitive assessment indicated limited understanding, highlighting their reliance on staff for proper care. The facility's policy on enteral feedings, dated November 2018, clearly outlines the necessity of elevating the HOB to prevent aspiration, yet this protocol was not followed during the observed incident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Licensed Vocational Nurse (LVN) 6 repositioned Resident 57 head of bed between 30-45 degree angle. LVN 6 evaluated Resident 57 for any negative or adverse outcomes. There were no negative or adverse outcomes related to this deficient practice for Resident 57. How do facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/5/25, the Director of Nursing (DON) made visual rounds to ensure all residents receiving enteral feeding head of bed were between 30 to 45 degrees. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/20/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to, LVNs and Registered Nurses and on the facility policy and procedure titled, "Enteral Feedings-Safety Precautions," with emphasis on ensuring the safe administration of enteral nutrition and preventing aspiration by elevating the HOB at least 30 degrees during tube feeding and at least one hour after feeding. The DON/designee will conduct rounds daily for 5 days weekly for 2 weeks and monthly thereafter to ensure residents receiving enteral feeding head of beds are at 30 to 45 degree angle. Department Managers will complete weekday rounds to ensure residents receiving enteral feeding head of beds are at 30 to 45 degree angle. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting on the status of the compliance for residents receiving enteral feeding head of bed is at 30 to 45 degrees for three months or until compliance is met. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/20/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to, LVNs and Registered Nurses and on the facility policy and procedure titled, "Enteral Feedings-Safety Precautions," with emphasis on ensuring the safe administration of enteral nutrition and preventing aspiration by elevating the HOB at least 30 degrees during tube feeding and at least one hour after feeding. The DON/designee will conduct rounds daily for 5 days weekly for 2 weeks and monthly thereafter to ensure residents receiving enteral feeding head of beds are at 30 to 45 degree angle. Department Managers will complete weekday rounds to ensure residents receiving enteral feeding head of beds are at 30 to 45 degree angle. The status of the compliance for residents receiving enteral feeding head of bed is at 30 to 45 degrees will be monitored for three months or until compliance is met.
Failure to Maintain and Assess PICC Line
Penalty
Summary
The facility failed to properly assess and maintain a Peripherally Inserted Central Catheter (PICC line) for a resident, identified as Resident 21. The deficiency involved the lack of assessment of the PICC line insertion site at least once every shift and the failure to change the dressing every seven days. This oversight was identified during a review of the resident's records and an interview with the Director of Nursing (DON), who confirmed that the site had not been assessed by a Registered Nurse (RN) and the dressing had not been changed since insertion. The facility's policy required regular monitoring and documentation of the PICC line site to prevent infection and ensure resident safety. Resident 21 had a medical history that included sepsis, diabetes mellitus, and hypertension, and was dependent on staff for personal hygiene. The resident was prescribed Meropenem intravenously for sepsis, necessitating the use of a PICC line. The DON acknowledged the importance of monitoring the PICC line for signs of infection, such as redness, swelling, and pain, and documenting these assessments in the IV Medication Administration Record (MAR). The facility's policy on PICC line maintenance emphasized the need for regular assessments and documentation to prevent complications.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Resident 21 PICC line orders for monitoring signs and symptoms, flushing, and maintenance including but not limited to dressing changes were inputted by the facility's Registered Nurse. There were no negative or adverse outcomes noted for Resident 21 regarding this deficient practice. How do facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/14/25, the Medical Records Director conducted an audit on active residents to ensure residents who have PICC line/Peripheral Intravenous (IV)/Midline lines have orders for monitoring signs and symptoms, flushing and maintenance orders including but not limited to dressing changes. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Director of Nursing in-serviced nursing staff, including but not limited to Licensed Vocational Nurses and Registered Nursing Staff, on the facility's policy and procedure titled "PICC Line Maintenance and Cleaning in a Skilled Nursing Facility," with emphasis on the facility ensuring safe and effective maintenance and cleaning of Peripherally Inserted Central Catheters (PICC lines) to prevent infection, maintain patency, and ensure patient safety. The in-serviced also included recording all assessments, dressing changes, flushing, cap changes, and any observed complications in the patient's medical records. The Medical Records Director/designee will conduct an audit on residents who are admitted or re-admitted with line orders, or receive IV orders in the facility, to ensure such residents have monitoring orders, flush orders, and maintenance orders including but not limited to dressing changes for their lines daily for 5 days, weekly for 2 weeks, and monthly thereafter. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for residents who have PICC line, Peripheral IV, midline lines, and have monitoring orders, flush orders, and maintenance orders for three months or until compliance is met.
Failure to Manage Resident's Pain in a Timely Manner
Penalty
Summary
The facility failed to manage pain for one resident, resulting in unnecessary pain. Resident 224, who was admitted with diagnoses including difficulty walking, muscle weakness, asthma, and congestive heart failure, was found to have their call light device out of reach, preventing them from requesting pain relief. The resident expressed experiencing back pain and a desire for Tylenol, which was prescribed as needed for mild pain. The care plan for Resident 224 included keeping the call system within reach and responding promptly to pain complaints, but these interventions were not followed. Interviews with facility staff, including an LVN and the DON, confirmed the importance of addressing pain promptly and the potential consequences of not doing so. The facility's policy on pain management emphasized timely intervention to prevent increased pain severity. However, the failure to ensure the call light was accessible led to a delay in addressing the resident's pain, contrary to the facility's policy and the resident's care plan.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25, Licensed Vocational Nurse (LVN) 5, administered two 325mg tablets of Tylenol pain medication to Resident 224. Pain medication was noted to be effective. On 3/4/25, Certified Nursing Assistant (CNA) 5, removed call light of the floor from behind Resident 224 bed and placed within reach of Resident 224. How do facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/18/25, Social Service Director and Social Service Assistant conducted resident interviews to ensure residents' pain was being managed. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/24/25, the Director of Nursing in-serviced Nursing Staff, including, but not limited to LVNs and Registered Nurses (RNs) on the facility's policy and procedure titled, "Pain Management," with emphasis on the facility being responsible for helping the resident obtain or maintain their highest level of well-being while working to prevent or manage the residents' pain. The in-service also included nursing staff, implementing timely interventions to reduce the increase in severity of pain which included administering pain medication as ordered. Department Managers, including but not limited to Director of Staff Development, Social Services Director and assistant, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, Minimum Data Set Nurse and MDSN Assistant, and Quality Assurance Nurse will conduct room rounds daily for five days weekly for two weeks in monthly thereafter to ensure resident's pain is being managed. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will review the Department Manager room rounds and will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for pain management with emphasis on administrating pain medication timely for three months or until compliance is met.
Failure to Administer Prescribed Eye Drops
Penalty
Summary
The facility failed to ensure that the prescribed eye drops for one resident, identified as Resident 100, were administered as ordered by the ophthalmologist. Resident 100, who was admitted with diagnoses including respiratory failure, epilepsy, and polycystic kidney disease, was found to have glaucoma and age-related nuclear cataracts in both eyes. The ophthalmologist prescribed Latanoprost and Cosopt eye drops to manage these conditions. However, the orders for these medications were not carried out, as confirmed during an interview and record review with a registered nurse (RN 1). The nurse acknowledged that the orders were faxed to the facility but could not locate any documentation of clarification from the physician, and the medications were not initiated. The facility's policy and procedure for telephone orders, dated May 2018, outlines the steps to reduce errors in verbal or telephone communication of physician orders. This includes documenting the order immediately on the prescriber order form with specific details such as date, time, patient name, drug name, strength, dose, frequency, route, quantity, duration, prescriber's name, and recipient's signature. Despite these guidelines, the failure to administer the prescribed eye drops was identified, which had the potential to worsen Resident 100's eye conditions.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/10/25, the Quality Assurance (QA) Nurse called Resident 100 ophthalmologist office to clarify, eyedrop order. The order was clarified to Brimonidine 0.2% (1) drop to both eyes two times a day, Cosopt 0.2% (1) drop to both eyes two times a day, & Latanaprost 0.005% (1) drop to both eyes at hour of sleep. The order was noted and carried out. Resident 100 had no negative outcomes as a result of this deficient practice. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/25/25, the Director of Nursing (DON)/designee conducted an audit on residents who went to an appointment within the past 30 days, to ensure orders from such appointments were noted and carried out. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/24/25, DON in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVN) and Registered Nurses (RN) on the facility policy and procedure titled, "Telephone Orders for Medication," with emphasis on reducing errors associated with misinterpreted verbal or telephone communication of physician orders by the receiver documenting the order immediately on the prescriber order form including the date and time order is received; patient name; drug name; strength, dose, frequency; route; quantity and/or duration; name of prescriber and the signature of the recipient. The DON/designee will conduct an audit of orders received from resident appointments daily for five days, weekly for two weeks, and monthly thereafter to ensure physician orders received from resident appointments are noted and carried out. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/25/25, the Director of Nursing (DON)/designee conducted an audit on residents who went to an appointment within the past 30 days, to ensure orders from such appointments were noted and carried out. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/24/25, DON in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVN) and Registered Nurses (RN) on the facility policy and procedure titled, "Telephone Orders for Medication," with emphasis on reducing errors associated with misinterpreted verbal or telephone communication of physician orders by the receiver documenting the order immediately on the prescriber order form including the date and time order is received; patient name; drug name; strength, dose, frequency; route; quantity and/or duration; name of prescriber and the signature of the recipient. The DON/designee will conduct an audit of orders received from resident appointments daily for five days, weekly for two weeks, and monthly thereafter to ensure physician orders received from resident appointments are noted and carried out. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for orders received from residents' appointments for three months or until compliance is met.
Improper Storage of Resident's Personal Food Item
Penalty
Summary
The facility failed to ensure safe and sanitary storage practices for foods brought to residents by family and other visitors, specifically for one resident. The deficiency was identified when a bottle of creamy horseradish, which required refrigeration after opening, was found on the bedside table of a resident. The bottle was not labeled with the resident's name, nor was it stored according to the manufacturer's directions. The facility's policy required perishable food items to be labeled, dated, and discarded after 48 hours if refrigerated, and discarded after 2 hours if left at the bedside. The resident involved was cognitively intact and had a medical history that included Vitamin D deficiency, hyperlipidemia, and gastro-esophageal reflux disease. During interviews, the resident confirmed that the horseradish was brought by her sister, and a Licensed Vocational Nurse acknowledged the failure to label and refrigerate the item. The Dietary Service Supervisor reiterated the policy that perishable items should not be left out for more than 2 hours and should be stored in the refrigerator if not consumed immediately. This oversight had the potential to cause foodborne illness to the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25, the Infection Control Preventionist removed the items from Resident 42 bedside. The Infection Control Preventionist explained the risk versus benefits of having items unrefrigerated to Resident 42. Resident 42 verbalized understanding and agreed for items to be discarded. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/4/25, the Infection Control Preventionist conducted visual rounds in residents' rooms to ensure that perishable items left at the bedside had the resident's name and date on the item, and if the item required refrigeration, that it was not left at the bedside for more than two hours. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/13/25, the Director of Staff Development and Administrator in-serviced facility staff, including but not limited to Certified Nursing Assistants (CNAs), Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), Dietary Staff, and Activities Department, on the facility's policy and procedure titled, "Food Brought in by Visitors," with emphasis on perishable food requiring refrigeration being discarded after 2 hours at bedside, and if refrigerated, it will be labeled, dated, and discarded after 48 hours. The in-service also included that if the resident desires to have food brought in, the Dietary Staff would provide education regarding safe food handling practices and need to have the resident's name and date it was brought to the facility. Department managers, including but not limited to the Director of Staff Development, Social Services Director and Social Service Assistant, Activities Director, Case Manager Admissions Coordinator, Infection Preventionist, Minimum Data Set Nurse (MDSN) and MDSN Assistant, and Quality Assurance Nurse, will conduct room rounds daily for five days weekly for two weeks, and then monthly thereafter, to ensure food brought into the facility is properly stored and labeled. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assurance and Performance Improvement (QAPI) Committee during its monthly meeting the status of the compliance for food brought into the facility by visitors, including whether it is stored properly, labeled, for three months or until compliance is met.
Failure to Document Resident Transfer to Hospital
Penalty
Summary
The facility failed to document in the clinical records of a resident who was sent to a General Acute Care Hospital from a dialysis center due to unresponsiveness. The resident, who was admitted to the facility with diagnoses including End Stage Renal Disease, anemia, and dysphagia, was picked up for dialysis in stable condition. However, the clinical records lacked documentation of the resident's transfer to the hospital, which was communicated to the facility by the resident's representative. During an interview and record review, a registered nurse acknowledged the omission, stating that she was busy and forgot to document the transfer. The facility's policy and procedure on nursing documentation requires that any communication with family, durable power of attorney, or physician should be noted in the nurse's notes. The failure to document the transfer had the potential to cause a delay in communication among staff and placed the resident at risk of not receiving appropriate care.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/10/25, the Director of Nursing verified with Resident 76's hemodialysis center events that led to Resident 76 being transported to the General Acute Hospital and documented in Resident 76's clinical chart as a late entry. How do the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/17/25, the Medical Records Director conducted an audit of all discharges, including but not limited to discharges to the hospital, home, or discharges to another facility. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/26/25, the Director of Nursing in-serviced the Nursing Staff, including but not limited to Licensed Vocational Nurses (LVN) and Registered Nurses (RN), on the policy and procedure titled, "Nursing Documentation," with emphasis on any communication with family, durable power of attorney, or physician, should be noted in the nurse's notes. The in-service also included ensuring documentation is inputted in the resident chart for discharges. The Medical Records Director will conduct an audit on discharge documentation daily for 5 days weekly for 2 weeks and monthly thereafter to ensure licensed nurses and registered nurses are documenting resident discharges in the resident's clinical progress note. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for clinical/nursing documentation related to discharges for three months or until compliance is met.
Violation of Resident's Right to Refuse Treatment
Penalty
Summary
The facility failed to respect a resident's right to refuse treatment, as outlined in their operational manual on Resident Rights: Refusal of Treatment. This incident involved a resident with a diagnosis of Type 2 Diabetes Mellitus, hypertension, and hoarding disorder, who was cognitively intact and capable of making decisions. On a specific date, the resident filed a complaint alleging that a Licensed Vocational Nurse (LVN) forcibly administered insulin despite the resident's refusal. The resident's blood sugar level was recorded at 355 mg/dl, and the physician had ordered five units of insulin, which the resident received without consent. Interviews with the Director of Nursing (DON) and LVN 3 revealed that the LVN attempted to educate the resident about the high blood sugar level and the need for insulin. However, the LVN admitted to administering the insulin without the resident's consent, acknowledging that it was against the resident's rights. The facility's policy clearly states that residents should not be forced to accept medical treatment and have the right to refuse it. The DON confirmed that the LVN should have waited for the resident's agreement before administering the medication.
CNA's Disrespectful Behavior Towards Residents
Penalty
Summary
The facility failed to ensure that four residents were treated with respect and dignity, as evidenced by the actions of a Certified Nurse Assistant (CNA 4). Resident 1 reported that CNA 4 was rude and spoke in a demanding voice during care. Resident 7 stated that CNA 4 refused to stay with her when requested during a bowel movement and often complained and spoke harshly. Resident 8 described CNA 4 as having a harsh personality and speaking loudly, while Resident 9 felt that CNA 4 was not nice and repositioned her in a hurried manner. The residents involved had various medical conditions, including diabetes mellitus, dysphagia, muscle weakness, major depressive disorder, schizophrenia, hemiplegia, hemiparesis, and epilepsy. These conditions required different levels of assistance with activities of daily living (ADLs), such as toileting, dressing, and transfers. The facility's policy on resident rights emphasized treating each resident with respect and dignity, which was not adhered to in these instances, potentially affecting the residents' self-esteem and psychosocial well-being.
Failure to Maintain Kitchen Sanitation
Penalty
Summary
The facility failed to ensure proper sanitation practices in the kitchen, as observed during a survey. Specifically, the kitchen floors were not swept and mopped as required by the facility's Cleaning Schedule. During an observation, food residue, dirt, and other debris were found on the floors behind black cabinets, around the dishwashing machine, under the sink, refrigerator, and stove. This lack of cleanliness was confirmed during an interview with a Dietary Aid, who acknowledged that the daily assigned dishwasher was responsible for sweeping after washing dishes. The Dietary Aid also noted that if the kitchen floor was not cleaned properly, it could lead to food contamination and attract pests. Further investigation revealed that the facility's Daily Cleaning Schedule, which required the floors to be swept and mopped three times daily, was not consistently followed. There was no documentation to support that the floors were cleaned on several specific dates. The Dietary Supervisor, upon reviewing surveyor pictures, admitted that some areas in the kitchen did not appear to have been cleaned daily. The facility's Policy and Procedure, dated May 1, 2018, required dietary staff to maintain a sanitary environment by adhering to the routine cleaning schedule, which was not followed in this instance.
Failure to Monitor Resident Leads to Multiple Elopements
Penalty
Summary
The facility failed to implement a care plan intervention to monitor a resident routinely, which resulted in the resident eloping from the facility unsupervised on multiple occasions. The care plan did not specify the type of supervision needed or how often the resident should be monitored. This lack of specificity and monitoring led to the resident leaving the facility without staff noticing, placing the resident at risk for serious medical complications. The resident involved had a history of elopement and was diagnosed with several medical conditions, including schizophrenia, COPD, diabetes mellitus, heart failure, atrial fibrillation, and hypertension. Despite these conditions and previous elopement attempts, the facility did not adequately monitor the resident's location or behavior. The care plan interventions were vague and not individualized to the resident's needs, failing to provide clear guidance on monitoring frequency or specific supervision requirements. Interviews with facility staff revealed that the resident's location and wandering behavior were not consistently monitored or documented. The staff did not perform visual checks as required, and the resident's care plan was not updated to reflect the need for a wanderguard bracelet until after the resident's third elopement. The facility's policy and procedures for wandering and elopement were not effectively implemented, contributing to the resident's repeated unsupervised departures.
Removal Plan
- The DON contacted the physicians of residents identified for being at risk for wandering/elopement to obtain orders to monitor each resident every 2 hours. The DON contacted the physicians of the residents identified with history of elopement to obtain orders to monitor each resident every 1 hour.
- Rounding during change of shift by outgoing and oncoming nursing staff (LVN, RN, and CNA) will take place to account for all residents with emphasis on identifying the whereabouts of residents that were at risk for elopement.
- The LVN or RN will record on the Medication Administration Record (MAR) their visual check of the residents and document in the progress note the location of the residents.
- Medical Records will audit the MAR for compliance of Licensed Staff documenting on residents who have orders to monitor every 2 hours for risk for wandering/elopement and 1 hour for residents with history of elopement. The audits will be daily for one week, weekly for two weeks, and monthly for 3 months thereafter.
- Medical Records will report to the Administrator/designee the findings of the audit daily for one week, weekly for two weeks, and monthly for 3 months thereafter.
- The MDS Coordinator reviewed the care plans for the nine residents identified for being at risk for wandering to ensure residents have measurable interventions.
- Resident interventions were updated to include interventions such as but not limited to monitor residents' location every 2 hours or 1 hour, Department Managers Monday through Friday and the RN Supervisor on weekends will provide room visits daily to provide orientation for socialization and sensory stimulation and apply wander guard bracelet by Admissions or Licensed Nurse.
- Licensed staff to complete wandering/elopement assessments on admission/readmission, quarterly and when a change of condition occurs.
- The QA Nurse updates the residents special need binders/postings as residents are identified.
- The Admissions Coordinator updates the facility wanderguard binder located at each station with resident's face sheets who were identified to be at risk to elope/wander and have wander guards applied as needed.
- Wander guard binder will be checked by Admissions or QA nurse during the weekday and designated RN/LVN on the weekend.
- All residents who have been identified to be at risk for elopement/wandering will have identifiable pink color name bands.
- Residents identified to be at risk will be discussed with facility staff during daily shift huddle and weekday stand-up meetings.
- Staff will be informed of the pink color name band, special need binder/posting and wander guard binder through in-services held by the Director of Staff Development, QA nurse and/or Administrator.
- The Administrator, DON, Director of Staff Development began in servicing facility staff, which included but not limited to Nursing, Housekeeping, Maintenance, Dietary, Department Managers including front door staff and contracted rehab staff, on residents at risk for wandering/elopement and what behaviors to monitor for each resident.
- The in-service also included facility's policy and procedure titled, Wandering & Elopement and Wandering Policy.
- The in-servicing is ongoing.
- The QA nurse will audit the in-service provided to staff daily and report the findings to the Administrator.
- The Administrator will ensure all staff on assignment and currently working daily are in-serviced.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse prevention program policy by not reporting an allegation of abuse involving a resident to the California Department of Public Health. The incident involved a family member who reported to a Licensed Vocational Nurse (LVN) that a Certified Nurse Assistant (CNA) raised their hand in a motion as if to hit the resident but did not make physical contact. The LVN reported the incident to a Registered Nurse (RN), who then sent the CNA home for the rest of the shift. However, the facility did not complete and fax the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to notify the state agency, as required by their policy. The resident involved was admitted to the facility with diagnoses including hemiplegia, hemiparesis following an intracranial hemorrhage, and syncope. The resident was cognitively intact according to their Minimum Data Set assessment. Despite the facility's policy requiring immediate reporting of abuse allegations, the staff did not report the incident to the state agency within the required timeframe. The facility's administrator confirmed that all allegations of abuse must be reported to the state agency, and acknowledged that the staff failed to report the abuse allegation on the evening of the incident.
Failure to Timely Report Investigation Results to CDPH
Penalty
Summary
The facility failed to submit the results of an investigation regarding an injury of unknown source to the California Department of Public Health (CDPH) within the required 5 working days for a resident. This resident, who was diagnosed with dementia, cerebral infarction with hemiparesis, and contractures, was noted to have a left humerus dislocation without swelling, bruising, or open areas. The Director of Nursing (DON) acknowledged that the incident was considered an unusual occurrence and that the initial report was submitted to the state licensing agency on the day of the incident. However, the Administrator (ADM) did not submit the final investigation report within the 5-day timeframe, as required by both the facility's policy and state and federal regulations. During interviews, both the DON and ADM confirmed the failure to comply with the reporting requirements. The facility's policies on unusual occurrence reporting and abuse prevention clearly state the necessity of submitting a final investigative report within 5 days, which was not adhered to in this case.
Failure to Secure Smoking Materials Poses Safety Hazard
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents who were smokers. Resident 1 was found with a cigarette lighter on his bedside table, despite having severe cognitive impairment and requiring supervision during smoking times. The facility's Smoking Safety Evaluation for Resident 1 did not include a system for the safe storage of smoking materials, which was a critical oversight given the resident's condition and the potential risks involved. Resident 2, who had intact cognition but was dependent on a wheelchair for mobility, was observed with a lighter and two cigarette sticks in her purse. The care plan for Resident 2 indicated that staff should provide a safe smoking environment and monitor the resident during smoke breaks. However, the Smoking Safety Evaluation form did not specify a secure storage system for her smoking materials, allowing her to keep them in her room, contrary to the facility's policy. Resident 3, who had cognitive impairment and required supervision while smoking, was seen in the hallway with cigarettes and a lighter. The resident's care plan emphasized the need for supervision and adherence to designated smoking areas, yet the facility failed to implement a secure storage system for his smoking materials. This lack of adherence to the facility's smoking policy and procedures posed significant safety risks, as residents were able to access and use lighters unsupervised, potentially leading to accidents or fires.
Removal Plan
- The DON, Admin, and Registered Nurse (RN) 1 informed all residents, both nonsmokers and smokers, that according to the facility's Smoking Policy and Procedure, residents will not keep cigarettes, e-cigarettes, and lighters in their possession, bedside or rooms. Residents were informed all smoking materials were to be kept at the nurses' Station 1 in a locked drawer and the activity office.
- The Director of Staff Development (DSD) Assistant and Social Service Designee (SSD) checked bedsides of all residents and ensured there were no cigarettes, e-cigarettes, or lighters at the bedsides. The DSD Assistant and SSD removed any cigarettes, e-cigarettes, and lighters found.
- Residents' bedside tables and nightstands were to be checked every shift by the assigned Certified Nursing Assistant (CNA) for 2 weeks, then daily for 2 months. Results of those rounds were to be reported to the charge nurse per shift. A log will be used to record results of rounds and reported to the charge nurse per shift. Residents found with cigarettes, e-cigarettes, and lighters will be removed immediately by the assigned CNA.
- A daily census will be used by the RN shift Supervisor to record the results of room observations during rounding. Residents found with cigarettes, e-cigarettes, and lighters will be removed immediately by assigned CNA.
- Of the 27 residents identified to smoke, nine residents were assessed by the shift RN, were unable to store smoking items at the bedside and the items should be secured by staff safely.
- The DON, Admin, DSD, and Designee in-serviced staff on checking to ensure there were no cigarettes, e-cigarettes, or lighters at any of the residents' bedsides and to remove those items for the safety and security of residents.
- The DON, Admin, DSD, and SSD held Resident Council Meetings to inform residents of the facility's smoking policy, specifically the safety of properly securing cigarettes, e-cigarettes, and lighters and of the deficient practice found by California Department of Public Health (CDPH) which placed the facility in non-compliance and in Immediate Jeopardy.
- The Admin ensured all 152 staff on assignment and who worked daily were in-serviced. Non-active staff, not currently on assignment and on leave, in-serviced prior to returning to assignment/work/duty.
- The Admin, DON, DSD, Quality Assurance (QA) Nurse, and RN 1 met with facility staff to educate staff on the facility's smoking P&P specifically the safe and secure storage of cigarettes, e-cigarettes, and lighters.
- The Admin posted a notice of the IJ at the front and rear entrance door, the activity room, and at all four Nurses' Stations to inform residents, families, and staff of the following: Visitors, friends, and family were not allowed to provide cigarettes, e-cigarettes, or lighters directly to the resident. These items must be checked in with the on-duty staff nurse. The nurses will place the smoking items at Station 1 in a locked drawer until picked up by the Activity Director. All residents' cigarettes, e-cigarettes, and lighter must be kept by the facility in Station 1 drawer and in the activity office's locked cabinet. The resident's name will be labeled on the cigarettes, e-cigarettes, and lighters. Residents who smoke, should not keep cigarettes, e-cigarettes, or lighters at their bedside. The 10 smoking sessions were held on the smoking patio located by Station 2 with supervision provided by the activity staff and assigned nursing staff for residents' safety. Residents that smoked should abide by the facility's policy regarding smoking session times to ensure residents, visitors, and staff safety.
- The Activity Supervisor who was in charge of the smoking sessions will report any concerns to the facility Admin in the daily meeting or as needed.
- The QA Nurse developed the Performance Improvement Plan (PIP) to address the assessment, safety, and storage of cigarettes, e-cigarettes, and lighters to ensure residents' safety. The QA nurse will monitor findings and report to the Quality Assurance Committee monthly for three months to ensure the system's effectiveness and performance was sustained.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to adhere to its policy and procedure for reporting allegations of abuse, as outlined in their Abuse Prevention and Prohibition Program. The policy mandates that any allegations of abuse, neglect, or other incidents that qualify as a crime should be reported immediately, but no later than two hours after forming the suspicion. However, the facility delayed reporting an incident involving unwanted physical contact between two residents to the California Department of Public Health (CDPH). The incident occurred at 9:35 a.m., but the report was not faxed to CDPH until 11:50 a.m., exceeding the two-hour reporting requirement. The deficiency involved two residents with cognitive impairments. One resident, admitted with diagnoses including cerebral infarction and schizophrenia, was noted to have severe cognitive impairment but was independent with mobility. The other resident, with diagnoses including encephalopathy and transient cerebral ischemic attack, had moderate cognitive impairment and required supervision for mobility. The Director of Nursing and the Administrator both acknowledged that the incident should have been reported within the stipulated two-hour timeframe to ensure a plan of correction was in place for resident safety. The failure to report in a timely manner delayed the investigation by CDPH.
Failure to Document and Implement Physician Orders for Urinary Catheter Care
Penalty
Summary
The facility failed to document and implement a physician's telephone order for a resident with a urinary catheter, leading to significant health issues. The resident, who had a history of benign prostate hyperplasia, adult failure to thrive, and cardiomegaly, was admitted to the facility and later readmitted with bladder distention and infection. The physician had ordered the monitoring of the resident's urinary catheter, including intake and output every shift, and to document any signs and symptoms of a urinary tract infection (UTI). However, the staff did not follow these orders correctly, as they documented the resident's output based on diaper changes rather than actual measurements, and failed to document the presence or absence of UTI symptoms as instructed. Further investigation revealed that a physician's order to flush the resident's catheter tubing was not documented or carried out, which contributed to the resident's condition worsening. The resident's progress notes indicated bloody urine, and the physician had ordered the catheter to be flushed and left in place for 10-14 days. However, this order was not found in the resident's order summary report, and the staff could not recall performing the catheter flush. This oversight led to a delay in treatment, resulting in the resident being transferred to a general acute care hospital (GACH) for further evaluation and treatment. At the hospital, it was discovered that the resident's urinary catheter balloon was inflated in the urethra, blocking urine drainage. This required the removal and reinsertion of the catheter, which relieved the resident by draining a significant amount of urine. The facility's policies and procedures for documentation and catheter care were not adhered to, as the nursing staff failed to provide accurate and timely documentation of the resident's status and care, contributing to the resident's adverse health outcome.
Failure to Provide Proper Cast Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate cast/splint care for five months after being transferred to the skilled nursing facility (SNF). The resident, a 56-year-old male with multiple diagnoses including a non-displaced fracture of the lateral malleolus of the right fibula, peripheral vascular disease, and hypertensive heart disease, did not receive proper cast care from the time of his admission. The initial admission assessment and subsequent documentation failed to mention the presence of the cast, leading to a lack of necessary care and services for the resident's condition. The resident's care plan did indicate the need for cast care, but this was not implemented or followed up on by the staff. Interviews with various staff members, including the treatment nurse, occupational therapist, and RN supervisor, revealed that there was a lack of awareness and communication regarding the resident's cast, resulting in no cast care being provided until the cast was removed by a hospital five months later. The treatment nurse admitted to not being aware of the cast during the initial assessment, and the occupational therapist confirmed the presence of the cast during the resident's treatment period. The RN supervisor acknowledged that the necessary orthopedic referral was not made, and the case manager indicated that follow-up appointments were not scheduled in a timely manner. The director of nursing (DON) confirmed that the facility failed to document and follow up on the resident's cast care, which could have led to complications such as worsening wounds, pain, and nerve problems. The facility's policy and procedure for cast care required regular inspection and documentation of the casted extremity, which was not adhered to in this case. The admission assessment policy also emphasized the need for thorough observation and communication with the resident and staff, which was not effectively carried out. This deficiency highlights a significant lapse in the facility's adherence to its own policies and procedures, resulting in inadequate care for the resident's casted leg.
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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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