Magnolia Gardens Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Granada Hills, California.
- Location
- 17922 San Fernando Mission Rd, Granada Hills, California 91344
- CMS Provider Number
- 055142
- Inspections on file
- 56
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Magnolia Gardens Convalescent Hospital during CMS and state inspections, most recent first.
Frayed and torn coverings on bed rails and a footboard were found in three residents’ rooms during observation. One resident had a large piece missing from black pipe insulation on the bed rail, another had gouged and frayed insulation on the side rails, and a third had torn pool noodles on the side rails and footboard. The MDSC, CNA, and ADON all acknowledged the items were not in good repair, and the resident with pool noodles stated they were already on the bed when she arrived.
Failure to document quantitative sleep hours for a resident receiving trazodone for depression and insomnia. The resident had severe cognitive impairment and the physician ordered staff to monitor hours of sleep each evening and night shift, but the MAR showed only check marks instead of measurable hours. RN, PHARM, ADON, and DON interviews confirmed the order should have required numeric sleep documentation, and the ADON stated the EHR order was entered incorrectly.
A facility failed to rotate insulin injection sites for a resident receiving Insulin Lispro, with the MAR showing repeated use of the same abdominal areas despite an order to rotate sites. The facility also did not complete or document several physician-ordered specialty referrals for another resident, including Urology, Neurology, Ophthalmology, Orthopedics, and Dermatology, and staff stated the referrals were their responsibility. In addition, the facility did not obtain ordered blood labs for a resident receiving atorvastatin and quetiapine, and RN and DON confirmed the labs were not drawn and no reason was documented.
The facility failed to keep smoking hazards controlled for two residents and failed to maintain bed rail padding in good repair for a resident with seizures. One resident who required supervision while smoking was observed smoking without staff present and kept her own lighter, while another resident had cigarettes and a lighter in his room despite records showing conflicting smoking supervision status and staff accounts. A third resident’s bed rail padding was missing in part and frayed, and the MDS coordinator and ADON noted it should have been reported and replaced.
A resident with low back pain had an order for PRN Tramadol for severe pain, and the care plan called for pain medication as ordered. Review of the CDR and MAR showed multiple Tramadol administrations where the controlled drug was documented as removed from the blister pack at one time, but the MAR was signed later. The DON and an LVN confirmed the MAR was not signed immediately after administration, creating a mismatch between controlled substance accountability records and the MAR.
A review of two medication carts found labeling and dating problems with eye drops for two residents. One resident’s artificial tears were labeled with a room number and last name instead of a full name, and another resident’s glaucoma drops had no open date on the box or bottle. The DON confirmed the facility’s policy requires resident medications to include the resident’s name and multi-dose containers to have an open date.
A facility failed to follow food safety standards when an evening cook did not take the temperature of an Asian salad during tray line service, even though the salad was already on resident trays. The facility also left a resident’s breakfast tray at the bedside for over 4 hours because she preferred to sleep late, and staff confirmed the tray was not removed, swapped, or reheated despite the facility policy requiring room trays to be removed within 2 hours.
A facility failed to maintain a clear controlled substance policy because its P&P did not specify when to sign the CDR or complete the MAR. During review of a resident receiving PRN Tramadol for pain, the CDR and MAR showed multiple mismatched and delayed documentation times. Interviews with an LVN, another LVN, an RN, and the DON showed inconsistent understanding of the proper sequence for removing, administering, and documenting controlled meds.
A resident with COPD and dementia was observed in the dining room while an AD stood over her and above eye level during feeding assistance. The AD later stated she should have been seated at eye level, and the ADON said best practice is for staff to sit at eye level to maintain respect and dignity during mealtime assistance. The facility’s Dignity policy stated residents must be provided with a dignified dining experience.
Failure to Inform Residents of Medications Before Administration: An LVN administered multiple medications to one resident with anxiety disorder and another resident with epilepsy, HTN, and delusional disorder without first telling them the medication names or indications. The residents were not given the opportunity to consent or refuse, and one resident stated she was uninformed of each medication. The DON stated LVNs are expected to review and name each medication before administration, and the facility’s Resident Rights policy required residents to be informed of and participate in their care and treatment.
Incomplete discharge paperwork for a resident lacked required details across the Discharge Summary, Post Discharge Plan of Care, and Transfer/Discharge Report. The SSD did not document confirmation of placement in the EMR, and RN and DON review found missing items such as the receiving board and care location/address, prognosis, IDT representative, resident address, mental/social status, DME, safety instructions, and responsible party information.
A resident’s smoking and safety assessment was completed inaccurately and left key sections blank. The resident had schizophrenia, major depression, muscle weakness, difficulty walking, intact cognition, a walker, one upper-extremity impairment, glasses, and some short-term memory impairment. The ADON stated the assessment was missing applicable items such as limited ROM and balance issues, and the form did not clearly show whether the resident could smoke independently or needed supervision, despite the care plan identifying the resident as a smoker requiring supervision.
Incomplete Care Planning for Dementia and Anticoagulant Therapy: A resident with vascular dementia, severe cognitive impairment, and significant ADL assistance needs did not have a care plan for the dementia diagnosis. The resident also received Eliquis for AFib, but the care plan did not include black box warning-related interventions, including the warning about premature discontinuation increasing the risk of thrombotic events.
A resident who routinely slept late had a care plan that left breakfast at the bedside until she woke up, but it did not include any alternate interventions even though staff observed the tray remaining untouched for hours and the resident said she preferred to eat later. Another resident’s care plan for smoking was also inconsistent, stating he required supervision while smoking while the interventions said he did not need supervision and had access to matches and lighters; the resident had schizophrenia, major depression, muscle weakness, difficulty walking, and some short-term memory impairment.
Failure to provide assistive device for resident communication: A resident with dementia and blepharitis was observed awake in bed but not responding when spoken to, and no communication board was found at the bedside. RN stated the resident had a communication deficit and could use a communication board to help express needs, while the facility policy for visually impaired residents referenced assistive devices such as glasses, contact lenses, magnifying lenses, and other devices used to assist with visual impairment.
Low Air Loss Mattress Set Incorrectly: A resident admitted with depression and sepsis had a physician order for a LALM set to 92 lbs, but the mattress was observed set at 120 lbs. The ADON confirmed the setting did not match the order and stated the higher setting made the mattress firmer and could potentially lead to skin impairment. The facility policy stated pressure-reducing mattresses are intended to prevent or minimize pressure on the skin.
Failure to Implement Ordered Continence Care: A resident with MS, DM II, and polyneuropathy had a physician order for a PureWick device that was not entered into the EMR and was not carried out. The DON stated the device was not used because the resident could not use it independently, even though he was bedbound, required max assist with ADLs, and could not use his left arm. The resident was using a handheld urinal that overflowed onto his abdomen and thigh, and there was no documentation that the physician was informed the order was not implemented.
A resident with a g-tube, significant cognitive impairment, and multiple chronic diagnoses had ordered Glucerna 1.2 enteral feeding via pump, but staff did not start the feeding at the ordered time. RN and LVNs confirmed the label was incomplete and inaccurate, with the wrong date, missing initials, missing amount, and no end time documented. The DON stated the facility policy required specific documentation for enteral feedings and continuous infusions.
Failure to coordinate dialysis lab monitoring and care planning for a resident with ESRD/HD. The resident had an elevated creatinine on facility labs, but staff could not locate current kidney function values and did not obtain post-lab results from the dialysis center. RN stated nurses should have contacted the dialysis center and notified the physician, and the DON stated the care plan should include resident-specific lab goals and related interventions.
Failure to Rotate Insulin Injection Sites: A resident with type 2 DM received Insulin Lispro injections in the abdomen without consistent site rotation on multiple occasions. The MAR showed repeated use of the same abdominal quadrants, and the ADON acknowledged the injections were not rotated as ordered. The resident’s order required site rotation, and the FDA label for Insulin Lispro also directs rotation to reduce the risk of lipodystrophy.
Insufficient Bedroom Space Per Resident: The facility failed to provide at least 80 sq. ft. per resident in 26 multiple-occupancy rooms. A room waiver request showed several 2-, 3-, and 4-bed rooms with less than the required space per resident, although residents and surveyors observed adequate room for movement, privacy curtains, and nursing care.
Menus were not consistently prepared in advance, followed, updated, or reviewed by a dietician, resulting in failure to meet the nutritional needs of residents.
A resident with ESRD and documented dislikes for pasta and rice was served rice at lunch, despite clear documentation of these preferences in their records and meal ticket. The RD confirmed that dietary preferences should have been honored and an appropriate substitute offered, in accordance with facility policy.
A dietary aide was observed with her personal cell phone in the food preparation area and was seen reaching for it during food service. The staff member acknowledged the phone should not have been there, and the RD confirmed that personal items must be kept away from food prep areas to prevent cross-contamination. Facility policy requires personal belongings to be stored separately from food service areas.
A resident with multiple diagnoses and moderate cognitive impairment was transferred to the hospital after a change in condition. The RN responsible for the transfer documented two sets of vital signs but recorded the same time for both, leading to a discrepancy. Additionally, the Resident Transfer Record was left incomplete, missing key information such as insurance details, symptom onset, diet order, mental status, and possessions. Both the RN and DON confirmed the documentation errors and omissions.
A resident was discharged without a complete Discharge Summary or Post Discharge Plan of Care, as required. The documentation lacked a recapitulation of the resident's stay, essential contact information, and details about the resident's status and care preferences. Discharge planning was also not included in the comprehensive care plan, as confirmed by the ADON during interviews and record reviews.
A resident with a history of cancer, dementia, and a recent prolonged fall was admitted without a required trauma care evaluation, despite facility policy mandating universal trauma screening. The Social Services Director confirmed the assessment was missed, and record review showed no trauma care evaluation was completed.
The facility did not ensure that care plans for two residents with pressure ulcers included specific low air loss mattress (LALM) settings and modes as required by physician orders, and failed to implement a fall prevention intervention (floor mat) for another resident with a history of falls. Staff interviews and record reviews confirmed that care plans were not comprehensive or individualized, and required interventions were not consistently implemented or documented.
A resident with diabetes experienced a critically low blood sugar level, and although an LVN intervened by administering orange juice and the blood sugar normalized, the physician was not notified as required by facility policy. The lack of documentation and notification was confirmed during interviews and record review, despite protocols mandating immediate provider notification for hypoglycemic events.
Two residents requiring low air loss mattresses for wound care or pressure ulcer prevention were found with incorrect mattress settings—one with the mattress in static mode instead of alternating, and another with the weight setting much higher than recommended. Nursing staff had not checked or adjusted the settings as required, and physician orders lacked specific instructions for mattress modes or levels. Facility policy and equipment manuals indicated that settings should be individualized based on resident weight and clinical needs.
A resident with cognitive impairment and multiple medical conditions was found in bed with the call light placed underneath her legs, making it inaccessible. Both a CNA and the ADON confirmed that the call light should have been within the resident's reach to allow her to request assistance, and that its inaccessibility could delay care. Facility policy requires call lights to be accessible to residents, but this was not followed in this instance.
Staff failed to knock before entering the rooms of four residents, including individuals with dementia, intellectual disabilities, and other medical conditions. The Infection Preventionist entered without requesting permission, which did not align with facility policy requiring staff to promote resident dignity and respect.
Two residents with severe cognitive impairment and high fall risk were observed using bed pad alarms, but neither had a care plan addressing the use of these alarms. Nursing staff confirmed the alarms were in use due to fall risk, and review of records showed the absence of required care plans with interventions or measurable objectives, contrary to facility policy.
A resident was found with medications and supplements stored at bedside despite not being assessed as safe for self-administration, making them accessible to others. Additionally, two residents at high risk for falls had bed pad alarms in use, but staff did not check or document the alarms' functionality as required by facility policy. These actions resulted in a failure to maintain a safe environment and adequate supervision.
Surveyors found an expired first aid kit stored in the medication room and a medication cart left unlocked and unattended in a hallway. Staff confirmed that expired items should be removed immediately and that medication carts must be locked when unattended, in accordance with facility policy.
Staff failed to follow infection control protocols, including not removing isolation gowns before leaving a resident's room on enhanced barrier precautions, not providing a trashcan for PPE disposal in a room under droplet isolation, allowing oxygen tubing to touch the floor, not labeling urinals for two residents, and not wearing full PPE when entering a room on transmission-based precautions for COVID-19 exposure.
Two residents with significant cognitive and physical impairments were found unable to access their call lights, despite care plans and facility policy requiring call lights to be within reach. Staff confirmed that the call lights were not accessible, which could result in delayed care for these residents.
A resident with an indwelling catheter and multiple diagnoses, including diabetes and obstructive uropathy, was admitted and required substantial assistance with daily activities. The baseline care plan created within 48 hours of admission failed to include necessary nursing interventions for catheter care, despite physician orders specifying daily care. Staff interviews and record reviews confirmed the omission, which did not meet facility policy for immediate care planning.
A resident receiving daily subcutaneous anticoagulant injections did not have injection sites rotated as required by professional standards and manufacturer instructions. Documentation in the MAR indicated repeated use of the abdomen without specifying or alternating the exact site, and nursing staff confirmed the lack of site rotation, which is necessary to prevent tissue damage and discomfort.
A resident with severely impaired cognition and limited English proficiency was not provided with a communication board, despite requiring substantial assistance with daily activities and having a care plan noting communication difficulties. Staff were unaware of the resident's primary language, and no communication board was found at the bedside, contrary to facility policy and expectations stated by the DON.
Two residents did not receive continuous oxygen therapy as ordered by their physicians, and two residents had oxygen tubing that was not dated or changed according to facility policy. Staff confirmed that physician orders and facility protocols for oxygen administration and equipment maintenance were not followed, as observed during surveyor visits and interviews.
A resident with end stage renal disease and on hemodialysis had a physician's order for fluid restriction, specifically requiring no water pitcher at the bedside. Despite this, surveyors observed a full pitcher and glasses of water at the bedside. Both an LVN and the DON confirmed that the physician's order was not followed, and facility policy required adherence to such orders.
A resident with multiple diagnoses and moderate cognitive impairment received nine prescribed medications significantly later than the scheduled administration time, resulting in a medication error rate of 32.14%. The nurse responsible cited being busy as the reason for the delay, and facility policy requires medications to be given within one hour of the prescribed time.
Two residents had leftover food brought by family or visitors that was not labeled with a resident identifier or use by date, nor properly refrigerated, as required by facility policy. Staff confirmed that these actions did not follow established procedures for food safety and storage.
The facility did not provide the required minimum of 80 square feet per resident in 26 multiple-resident rooms, with room sizes ranging from 72 to 79 square feet per resident. Despite this, residents and staff reported adequate space for care and mobility, and rooms were equipped with privacy features and necessary furnishings.
The facility failed to conduct psychosocial assessments upon admission for two residents and did not make follow-up calls to three residents after discharge. This oversight involved residents with severe cognitive impairments and physical disabilities, highlighting a lapse in ensuring safe transitions and adequate support post-discharge.
A resident with a cardiac pacemaker and atrial fibrillation had an apical pulse exceeding 100 bpm on multiple occasions. An LVN failed to document notifying the physician, as required by the facility's policy. This lack of documentation risked the resident's care due to incomplete medical records.
A resident was administered ivermectin for a body rash without a scabies diagnosis. Despite having conditions like atrial fibrillation and type 2 diabetes, there was no documented evidence of scabies, which ivermectin is used to treat. The Infection Preventionist confirmed the medication was given without proper diagnosis, highlighting unnecessary use and potential adverse effects.
The facility failed to ensure proper reconciliation of controlled medications for Medication Cart A, as licensed nurses did not consistently sign the Controlled Drugs Accountability Sheet (CDAS) for several shifts. This lapse in protocol, confirmed by both an LVN and the DON, could lead to inaccurate reconciliation and risk of drug diversion. The facility's policy requires both outgoing and incoming nurses to count and sign for controlled substances together, with discrepancies reported immediately.
The facility failed to ensure call lights were within reach for two residents with severe cognitive impairments, as observed during staff interviews. Both residents required total assistance, and their care plans specified that call lights should be accessible. Staff found the call lights out of reach and repositioned them, acknowledging the oversight.
Frayed Bed Rail and Footboard Coverings
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents by allowing bed rail and footboard coverings to remain frayed, torn, worn down, and in one case missing a large piece. During an initial pool observation, black pipe insulation wrapped around the side rails of one resident’s bed was observed with a large piece missing on the right side and the remaining material worn down and frayed. The Minimum Data Set Coordinator observed the condition and stated the insulation should have been reported and replaced right away for safety, cleanliness, and appearance. A second resident, who had diagnoses including seizures and dementia and was documented as completely dependent on staff for all ADLs, was observed with black pipe insulation on the side rails of the bed that had gouges, was worn down, and frayed. A CNA observed the condition and stated it should have been reported so it could be replaced. The ADON later stated the insulation should not be torn and frayed because it is harder to keep clean and should be in good repair, especially in the resident’s room. A third resident, admitted with weakness and hypertension and requiring assistance with multiple ADLs, was observed with pool noodles wrapped around the side rails and footboard of the bed. The resident stated the pool noodle had already been there on arrival and did not know why it was on the bed. On closer inspection, the pool noodles on the footboard were torn and frayed with part sticking outward. The ADON confirmed the condition and stated the room and environment were not homelike and that the pool noodles needed to be repaired. The facility policy stated residents are to be provided a safe, clean, comfortable, and homelike environment with clean, sanitary, and orderly surroundings.
Failure to Document Quantitative Sleep Hours for Trazodone Monitoring
Penalty
Summary
The facility failed to monitor hours of sleep for a resident who was prescribed trazodone at bedtime for depression manifested by inability to sleep or rest at night causing stress. The resident was admitted with a diagnosis of depression and had severe cognitive impairment with skills required for daily decision making, and the MDS indicated the resident required setup assistance with eating and had taken an antidepressant during the assessment period. The physician order dated 11/22/2025 directed staff to monitor hours of sleep for trazodone use every evening and night shift. Review of the MARs from 11/2025 through 4/8/2026 showed the resident’s sleep documentation was recorded with a check mark rather than quantitative, measurable hours. During interview and record review, RN 1 stated there should be a place for licensed nurses to enter the hours of sleep, the consultant pharmacist stated she expected a quantitative number when an order required monitoring sleep hours, and the ADON stated she had entered the order incorrectly by selecting an option for no documentation needed instead of requiring a quantitative entry. The DON stated licensed nurses should have been documenting quantitative hours of sleep because it was important to determine whether the medication was effective or needed adjustment or discontinuation.
Failure to Follow Medication Administration, Referral, and Lab Monitoring Orders
Penalty
Summary
The facility failed to ensure Resident 85 received insulin injections in accordance with the order to rotate sites. Resident 85 was admitted with diagnoses including type 2 diabetes mellitus and depression, and the order for Insulin Lispro 100 units/ml directed administration subcutaneously before meals and at bedtime with site rotation. Review of the MAR showed multiple insulin administrations to the same abdominal quadrant on several occasions between 2/4/2026 and 4/5/2026, including repeated use of the right upper quadrant, left upper quadrant, left lower quadrant, right lower quadrant, and repeated use of the right upper quadrant on consecutive dates. The ADON reviewed the MAR and stated there were multiple instances where the injection sites were not rotated and that licensed nurses are expected to rotate insulin injection sites each time. The facility also failed to ensure timely follow-up and implementation of physician-ordered specialty referrals for Resident 98. Resident 98 was admitted with diagnoses including multiple sclerosis, type 2 diabetes mellitus, polyneuropathy, major depressive disorder, and hyperlipidemia, and the H&P stated the resident had the capacity to understand and make decisions. A physician order dated 4/3/2026 included referrals to Urology and Neurology, and additional consultation orders for Ophthalmology, Orthopedics, and Dermatology were also identified. RN 1, the SSD, and the DON each stated that nursing staff were responsible for carrying out and coordinating specialty referrals, but documentation reviewed did not show that the orders were implemented, and the SSD stated she had not received notification of the referrals. The facility further failed to follow physician orders for laboratory monitoring for Resident 11. Resident 11 had diagnoses including hyperlipidemia and schizoaffective disorder, was severely cognitively impaired, and was receiving atorvastatin and quetiapine. Physician orders dated 2/19/2026 required a lipid panel, CMP, HgA1c, and EKG every six months. RN 1 reviewed the record and was unable to find any blood labs drawn in 2026, and found no documentation explaining why the labs were not completed. The DON confirmed that no blood labs were drawn after the order date and stated she was not sure why the blood labs were not done, although an EKG was completed.
Unsafe Smoking Access and Damaged Bed Rail Padding
Penalty
Summary
The facility failed to provide an environment free from accident hazards for three residents. One resident who was identified in the care plan as needing supervision while smoking was observed smoking outside without staff present, and the resident stated she kept her own lighter because staff had lost it previously. The care plan for that resident stated she required supervision while smoking and was to have no access to matches or lighters, while the facility’s smoking policy required direct supervision for residents needing monitoring and prohibited access to smoking items without independent smoking privileges. A second resident was observed with an opened pack of cigarettes in his shirt pocket and later wheeled himself to the smoking area without alerting staff. A staff member then noticed him and stayed to supervise while he was already smoking. The resident’s family member stated the resident kept cigarettes in his room and had a lighter there, while staff gave conflicting accounts about where cigarettes and lighters were stored. The resident’s smoking care plan stated he needed no supervision and had access to matches and lighters, but a prior smoker risk assessment identified him as requiring supervision as a non-independent smoker. A third resident with diagnoses including seizures and dementia had black pipe insulation wrapped on the bed side rails, and during observation the MDS coordinator noted a large piece was missing from the right side and the remaining insulation was worn down and frayed. The MDS coordinator stated the insulation should have been reported and replaced right away for safety, cleanliness, and appearance. The ADON stated the insulation should not be torn and frayed and should have been reported to maintenance immediately, especially because the resident had a history of seizures. The facility’s homelike environment policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment.
Controlled Drug Documentation Did Not Match MAR Entries
Penalty
Summary
The facility failed to ensure the Controlled Drug Record (CDR) coincided with the Medication Administration Record (MAR) for one sampled resident receiving Tramadol for severe pain. The resident was admitted with low back pain, was cognitively intact, and had an order for Tramadol 50 mg every six hours as needed for severe pain. The care plan included administering pain medication as ordered, and the pain assessment indicated the resident had pain frequently in the last five days. Review of the resident’s CDR and MAR showed multiple instances where Tramadol was documented as removed from the blister pack on one date and time, but the MAR was signed at a later time, including entries on 4/1, 4/2, 4/3, 4/4, 4/5, and 4/6. During interviews, an LVN stated that nurses document on the CDR and MAR after giving the medication, and the DON stated the MAR needs to be signed immediately after administration. The DON also reviewed the facility’s Controlled Substances policy, which required the nurse to record the resident name, medication name, strength and dose, time of administration, method of administration, quantity remaining, and nurse signature, but did not specify which documents were to be signed or the steps for documenting controlled substance removal.
Medication Labeling and Dating Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles for two residents on two medication carts. Resident 17, who was admitted with diagnoses including hypertension and was severely cognitively impaired with substantial/maximal assistance needed for personal hygiene, had an order for artificial tears ophthalmic solution 1% to be instilled in both eyes three times daily for chronic dry eye syndrome. During a medication cart observation, the artificial tears for this resident were found labeled with a room number and last name rather than the resident’s first and last name. Resident 21, who was admitted with a diagnosis of glaucoma and was also severely cognitively impaired with substantial/maximal assistance needed for personal hygiene, had physician’s orders for brimonidine tartrate ophthalmic solution 0.2% twice daily and latanoprost ophthalmic solution 0.005% at bedtime for glaucoma. During a concurrent medication cart observation, the resident’s brimonidine and latanoprost eye drops were observed without an open date on the box or bottle. The DON reviewed the facility policy titled Labeling of Medication Containers, which stated individual resident medications should include the resident’s name and that multi-dose containers should have an open date recorded when opened. The DON also stated that eye drops not labeled by the pharmacy should be labeled with the resident’s first and last name, and that an open date is needed for multi-dose containers to ensure the medication remains effective.
Food Temperature and Tray Removal Failures
Penalty
Summary
The facility failed to serve food in accordance with professional standards for food service safety when the evening cook did not take the temperature of the Asian salad during tray line service. During the tray line observation, the salad had already been placed on residents’ trays before its temperature was checked, and the Dietary Supervisor then took and recorded the temperature. The evening cook stated he was supposed to take the salad temperature but forgot because he was completing many tasks. The Dietary Supervisor stated the cook is responsible for taking the soup and salad temperatures, and the facility policy required all hot and cold food temperatures to be taken prior to every meal service and recorded on the temperature log. The facility also failed to follow safe food handling procedures for Resident 20, who was admitted with COPD and PVD and was documented as having the capacity to understand and make decisions. Resident 20 was observed asleep in bed while her breakfast tray remained on the bedside table. She stated she eats after waking up, usually around 11:00 to 11:30 a.m., and asked staff not to touch the tray. The tray remained in the room untouched during later observation, and Resident 20 was later seen eating the same breakfast tray that had been left at her bedside. Staff confirmed the tray was left in the room for the resident to eat later and was never removed, swapped, or heated up. The CNA stated there was a chance of food poisoning if the food was left out that way, but staff left it so residents would not complain or become upset. The Dietary Supervisor and the ADON stated the tray should have been removed sooner, and the facility policy required meal trays delivered to resident rooms to be removed within 2 hours of delivery, with an alternate meal or reheated tray provided upon request.
Controlled substance documentation policy lacked clear timing and sequence requirements
Penalty
Summary
The facility failed to establish and implement a clear policy for controlled drug administration because its Controlled Substances policy did not specify the required timeframes for documenting controlled medications, including when to sign the Controlled Drug Record (CDR) and when to complete the Medication Administration Record (MAR). During record review, observation, and interviews, three licensed nurses were unable to identify the proper chronological steps for removing and administering controlled medications. The facility’s policy stated that the nurse administering the medication was responsible for recording the resident name, medication name, strength and dose, time of administration, method of administration, quantity remaining, and nurse signature, but it did not clearly state the order in which the CDR and MAR were to be completed. Resident 35 was admitted with low back pain and was cognitively intact, able to make daily decisions, and independent with eating and oral hygiene. The resident had an order for Tramadol 50 mg every six hours as needed for severe pain. Review of the resident’s CDR from 4/1/2026 through 4/7/2026 and the April 2026 MAR Audit Record showed multiple discrepancies between the times the medication was removed and the times it was documented on the MAR. The CDR reflected Tramadol being removed at scheduled times, while the MAR showed documentation at different times, including entries documented later than the administration times and one entry documented on a different date than the CDR entry. During interviews, LVN 1 stated she removed the controlled pain medication, placed it in a cup, asked the resident to rate pain, and then returned to the cart to sign the CDR and MAR after the resident agreed to take the medication. LVN 3 and RN 1 also stated that both the MAR and CDR were signed after the medication had been given. LVN 5 confirmed delayed documentation on several Tramadol administrations and stated she should have signed the MAR immediately after administering the medication. The DON stated the process should include removing the medication, signing the CDR, locking the cart, explaining the medication to the resident, administering it, and then immediately signing and documenting in the electronic MAR, and also stated the policy did not specify the correct order of steps.
Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity during feeding assistance when a staff member stood over the resident rather than being at eye level. Resident 75 was admitted on 2/25/2021 and readmitted on 10/24/2025 with diagnoses including COPD and dementia. The resident’s H&P dated 2/23/2026 stated she did not have the capacity to understand and make decisions, and the MDS dated 4/7/2026 indicated she could make herself understood but only sometimes understood others and was dependent on facility staff for toileting, bathing, and dressing. During an observation on 4/6/2026 at 12:12 p.m. in the dining room, Resident 75 was sitting in her wheelchair at a table while the Activities Director stood over her and above eye level while assisting her with eating. During interview, the AD stated she should have been sitting on a chair and at eye level while assisting the resident with eating, and said it was important to sit and interact with the resident while assisting with eating for respect and dignity. The ADON also stated that the best practice when assisting residents with eating is for staff to sit at eye level to maintain respect and dignity and for safety purposes. The facility’s Dignity policy, last reviewed 3/9/2026, stated that when assisting with care, residents must be provided with a dignified dining experience.
Failure to Inform Residents of Medications Before Administration
Penalty
Summary
The facility failed to ensure that residents were informed of their medications and the reasons for taking them before administration. For one resident with diagnoses including muscle weakness and an anxiety disorder, the MDS showed the resident could make self-understood and understand others, and was independent with several activities of daily living. During a medication pass observation, an LVN prepared and administered multiple medications, including artificial tears, aspirin, cetirizine, citalopram, cyclosporine, docusate sodium, furosemide, gabapentin, multivitamin, and Seroquel, without telling the resident the medication names or indications and without giving the resident the opportunity to consent or refuse them. The LVN later stated that residents must be informed of the medications they are taking and given the opportunity to refuse any or all medications, and acknowledged that not informing the resident of the medications and their indications was a violation of resident rights. The facility policy on Resident Rights stated that employees shall treat residents with kindness, respect, and dignity and that residents are to be informed of and participate in their care planning and treatment. A second resident, admitted with epilepsy, hyperlipidemia, hypertension, and delusional disorders, had an MDS indicating the ability to understand others with clear comprehension but could never or rarely understand and make decisions. During a concurrent observation, interview, and record review, an LVN administered ordered medications including amlodipine, aspirin, cyanocobalamin, docusate sodium, lisinopril, risperidone, and valproic acid without reviewing and verifying each medication with the resident. The resident stated she was uninformed of each medication, and the LVN stated she did not review and verify each medication because she was too busy. The DON stated LVNs are expected to identify the resident, verify the right medication and related details, and review and name each medication and side effects before administration.
Incomplete discharge documentation for a resident
Penalty
Summary
The facility failed to ensure that discharge documentation for one resident included all required elements, including the reason for transfer or discharge, the effective date, and the receiving location. Resident 102’s record showed admission with diagnoses including HTN, asthma, left hip dislocation, hypotension, and hypothyroidism, and the resident was discharged from the facility. The resident’s H&P stated the resident had the capacity to understand and make decisions, and the MDS indicated cognition was intact and that the resident required partial/moderate assistance with bathing, lower body dressing, and footwear. During interview and record review, the SSD stated she assists with discharge planning by arranging DME and coordinating placements in lower levels of care, and that EMR documentation should include contact discussions, confirmation of placement, and the date and time of each entry. The SSD stated she did not document the confirmation of placement for Resident 102. She also stated that the lack of documentation resulted in no evidence that placement occurred for the resident and that nursing staff should have contacted her if additional information was needed to complete the discharge report. RN 1 reviewed the resident’s Discharge Summary Report, Post Discharge Plan of Care, and Transfer/Discharge Report and stated each contained missing elements. RN 1 stated the Discharge Summary Report lacked prognosis, the IDT representative, and the location of the board and care; the Post Discharge Plan of Care lacked the location of the board and care, the resident’s address, mental and social status, medical equipment and supplies, safety precautions and instructions, and the responsible party’s name; and the Transfer/Discharge Report did not include the address of the board and care. The DON stated the SSD did not document in progress notes and that emails were not included in the extended chart, and confirmed that the discharge forms were missing required information, including the board and care location and address.
Incomplete Smoking and Safety Assessment
Penalty
Summary
The facility failed to accurately complete a smoking and safety assessment for one of two sampled residents reviewed under the smoking care area. Resident 7’s face sheet showed admission with diagnoses including schizophrenia, major depression disorder, muscle weakness, and difficulty walking. The MDS indicated the resident’s cognition was intact, the resident used a walker, had impairment to one upper extremity, wore glasses, and had some short-term memory impairment. The care plan report identified Resident 7 as a smoker who requires supervision during smoking, with a goal that the resident would smoke according to facility policy and with precautions for the resident’s safety and the safety of others. However, the care plan section of the Smoking and Safety assessment dated 4/2/2026 was blank, and the ADON stated the assessment was incomplete and inaccurate because it was missing documentation for items that applied to Resident 7, including limited range of motion and balance issues. The ADON also stated the current smoking assessment did not meet the facility’s policy requirements for a smoking evaluation and that the new form did not clearly indicate whether a resident may smoke independently or needs supervision.
Incomplete Care Planning for Dementia and Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for Resident 23 that addressed the resident’s vascular dementia diagnosis. The admission record showed the resident was admitted on 3/11/2024 and later readmitted with diagnoses including vascular dementia and long-term use of anticoagulant. The MDS dated 2/07/2026 indicated the resident’s cognitive skills for daily decision making were severely impaired and that the resident required partial/moderate assistance with oral hygiene and personal hygiene, and substantial/maximal assistance with toileting hygiene, lower body dressing, and putting on/taking off footwear. During a concurrent interview and record review on 4/08/2026, the ADON reviewed the resident’s care plans and stated there was no care plan developed for the vascular dementia diagnosis. The facility also failed to include appropriate care planning interventions for the resident’s Eliquis (Apixaban) order for atrial fibrillation. The ADON reviewed the order for Eliquis Oral Tablet 2.5 mg, one tablet by mouth two times a day, and stated that Eliquis carries a black box warning and should be care planned. The care plan for Eliquis, initiated on 11/01/2025 with a target date of 5/19/2026, did not include interventions such as a warning that premature discontinuation of any oral anticoagulant can increase the risk of thrombotic events. The facility’s policy on comprehensive person-centered care plans stated that interventions are chosen after data gathering and clinical decision making, and the black box warning policy stated that a black box warning denotes a serious or life-threatening potential side effect associated with the medication.
Care plans not updated for meal tray timing and smoking supervision
Penalty
Summary
The facility failed to update and revise Resident 20’s care plan to address meal tray management for a resident who routinely sleeps late and prefers to eat after waking. Resident 20 was admitted with diagnoses including COPD and PVD, and the H&P indicated the resident had the capacity to understand and make decisions. The MDS indicated the resident was usually understood by others and required setup/clean-up assistance and partial assistance with oral and personal hygiene. During an observation and interview, Resident 20 was found asleep in bed with a breakfast tray on the bedside table that had not been eaten. The resident stated she typically wakes and eats around 11:00 a.m. to 11:30 a.m. daily and did not want the tray touched. The care plan, titled for resident non-compliance and noting that meal trays were left on the table until she woke up per her request, did not include alternative interventions to leaving the tray at the bedside. The tray remained in the room later that morning and was still untouched until the resident ate from the same tray around 11:48 a.m.; the resident stated she did not request that the meal be replaced or reheated. The facility also failed to revise Resident 7’s care plan so the interventions matched the stated smoking supervision need. Resident 7’s record showed diagnoses including schizophrenia, major depressive disorder, muscle weakness, and difficulty walking, and the MDS indicated intact cognition, use of a walker, impairment to one upper extremity, glasses use, and some short-term memory impairment. The care plan focus stated the resident required supervision while smoking, but the interventions stated the resident did not require supervision while smoking and had access to matches and lighters. The ADON reviewed the care plan and stated the focus and interventions were in conflict and that the care plan had not been revised to reflect accurate interventions.
Failure to Provide Assistive Device for Resident Communication
Penalty
Summary
Assist a resident in gaining access to vision and hearing services was cited after surveyors found that Resident 93, who had diagnoses including dementia and blepharitis, was not provided with assistive devices to help communicate needs to the care team. The admission record showed the resident was originally admitted on 1/9/2015 and later readmitted, and the MDS dated 1/06/2026 indicated the resident could make self-understood and usually understand others, but required substantial to maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene, and was dependent on staff for toileting hygiene, showering, lower body dressing, and putting on/taking off footwear. During a concurrent observation and interview on 04/06/2026 at 1:10 p.m., RN 1 observed the resident awake in bed but not replying when spoken to. RN 1 searched the bedside table for a communication board, but none was found. RN 1 stated the resident had a communication deficit and could use a communication board to help express needs and facilitate communication, and stated it would be frustrating if the resident could not be understood by staff and staff could not provide the right intervention due to the resident's impaired vision and communication deficit. The facility policy on visually impaired residents stated that residents with visual impairment would be assisted with activities of daily living as appropriate and that assistive devices to maintain vision include glasses, contact lenses, magnifying lens, and any other device used by the resident to assist with visual impairment.
Low Air Loss Mattress Set Incorrectly
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to ensure Resident 54's low air loss mattress was set according to the physician's order. Resident 54 was admitted on 3/24/2026 with diagnoses including depression and sepsis. The H&P dated 3/25/2026 indicated the resident was alert and oriented x 2 with fluctuating capacity. During a concurrent interview and record review on 4/08/2026, the ADON reviewed the physician's order for a low air loss mattress set according to weight at 92 lbs. During a concurrent observation and interview in the resident's room, the mattress setting was found to be set at 120 lbs. The ADON stated the setting was not accurate according to the physician's order and that the higher setting made the mattress firmer and could potentially lead to skin impairment for Resident 54. The facility policy titled Pressure-Reducing Mattress indicated the objective was to provide mattresses that will prevent and/or minimize pressure on the skin.
Failure to Implement Ordered Continence Care
Penalty
Summary
The facility failed to provide appropriate continence care and interventions for one sampled resident who was admitted with multiple sclerosis, type 2 diabetes mellitus, polyneuropathy, major depressive disorder, and hyperlipidemia. The resident’s history and physical stated that he had the capacity to understand and make decisions. A physician order for a PureWick device was written for the resident, but the order was not entered into the EMR, and there was no documentation in the nursing notes showing that the order was carried out or that the physician was informed it was not implemented. During interview, the DON stated she did not carry out the PureWick order because she believed the resident would need to use it independently and that it was not appropriate since he was unable to use it. The DON also stated the resident was bedbound, required maximum assistance with ADLs, and was unable to use his left arm. She stated he was currently using a handheld urinal, but the urine overflowed onto his abdomen and thigh, and that there were no other urinal options available for him. The facility policy on urinary continence and incontinence stated that staff and the physician would provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections, and that assessments should consider diagnoses such as MS and functional limitations such as impaired mobility and decreased manual dexterity.
Enteral Feeding Not Properly Labeled and Not Started on Time
Penalty
Summary
The facility failed to ensure enteral feeding for one resident with a gastrostomy tube was properly labeled for medication and solution and failed to administer the prescribed enteral feeding on time. The resident was admitted with diagnoses including cerebral palsy, bipolar disorder, schizophrenia, hypotension, and hypothyroidism, and the H&P stated the resident was alert but not oriented, had significant cognitive impairment, and lacked capacity to make independent medical decisions. For the labeling issue, RN 1 reviewed the physician’s order for Glucerna 1.2 at 65 cc per hour for 20 hours via feeding pump and stated the feeding started at 4:13 p.m., not at 12:00 p.m. as ordered. During observation and interview, LVN 3 stated she was assigned to the resident and did not start the enteral feeding at 12:00 p.m. as ordered. LVN 3 and LVN 4 reviewed the enteral feeding label and stated the date should have read 4/6/2026 instead of 4/7/2026, LVN 3’s initials were missing, the amount of enteral feeding was not documented, and the end time was not written on the label. For the timing issue, RN 1 reviewed the MAR and confirmed the feeding was started later than ordered. LVN 4 stated he was aware the enteral feeding did not start at 12:00 p.m. and that he paused the enteral feeding at 9:30 a.m. with 500 cc remaining. The DON stated licensed nurses should follow the facility policy for enteral tube feeding via continuous pump and acknowledged that delayed feedings should be documented and the physician and family representative notified. The facility policy required the formula label to document initials, date and time the formula was hung/administered, and that the label was checked against the order, and the continuous infusion policy required documentation of date and time, medication/solution, rate of infusion, and complications and interventions.
Failure to Coordinate Dialysis Lab Monitoring and Care Planning
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for Resident 31, who had ESRD and received hemodialysis on Monday, Wednesday, and Friday. The resident’s MDS dated 1/14/2026 indicated the resident was cognitively intact and required setup assistance with eating. The physician’s orders dated 3/04/2026 included dialysis treatments with a 9 a.m. chair time. The facility’s care plan for weight variance, initiated 6/28/2026, identified a potential for weight variance due to fluid retention secondary to ESRD/HD and included an intervention to copy monthly labs from the dialysis center. The care plan for chronic anemia, also initiated 6/28/2023, included communicating with the dialysis center as indicated and notifying the physician and responsible party of a change in condition. Facility lab values dated 2/19/2026 showed a creatinine level of 4.70 mg/dL, and dialysis center lab values showed creatinine levels of 7.39 mg/dL on 3/2/2026 and 7.29 mg/dL on 4/1/2026. During interview and record review, RN 1 was unable to find current kidney function lab values and stated the licensed nurses should have called the dialysis center to obtain labs after the elevated creatinine result and should have had a conversation with or made a recommendation to the physician for interventions. RN 1 also stated the resident’s dialysis care plan should have included a resident-centered goal range for creatinine and interventions when the creatinine was outside that range. The DON stated the care plan should have a goal to maintain blood laboratory values in the appropriate resident-specific range and that if labs did not fall within that range, additional dialysis may be needed.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure Resident 85 was free from significant medication errors by not consistently rotating insulin injection sites as ordered. Resident 85 was admitted with diagnoses including type 2 DM and depression, and the MDS dated 2/1/2026 indicated the resident could usually make herself understood, sometimes understood others, and was dependent on staff for toileting, dressing, bathing, and personal hygiene. The resident was receiving hypoglycemic agents, and the order for Insulin Lispro Injection Solution 100 units/ml, dated 2/28/2026, directed staff to administer the insulin subcutaneously before meals and at bedtime and to rotate sites. A review of the MAR from 2/4/2026 through 4/5/2026 showed multiple insulin administrations in the abdomen without consistent site rotation, including repeated use of the RUQ, LUQ, LLQ, and RLQ on several occasions. During interview and record review, the ADON acknowledged there were multiple instances in which insulin injection sites were not rotated and stated that insulin administration sites should be rotated to prevent damage to the resident's skin tissue. The ADON further stated that failure to follow the physician's order to rotate insulin injection sites constituted medication errors. The facility policy required medications to be administered in accordance with prescriber orders, and the FDA label for Insulin Lispro indicated injection sites should be rotated to reduce the risk of lipodystrophy.
Insufficient Bedroom Space Per Resident
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 26 of 40 multiple resident rooms, including rooms 101, 103, 105, 106, 107, 108, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119, 120, 123, 126, 133, 136, 137, 138, 139, 140, and 141. The room waiver request dated 4/06/2026 showed that these rooms ranged from 155 to 316 square feet and were assigned to 2, 3, or 4 residents, resulting in less than the required square footage per resident. The minimum requirement cited in the report was 160 square feet for a 2-bed room and 360 square feet for a 4-bed room. During the recertification survey, residents in the rooms with the waiver were observed to have enough space to move freely, and there was adequate room for wheelchairs, walkers, canes, and the operation of nursing equipment. The facility’s waiver letter stated that the rooms were in accordance with the special needs of the residents, would not adversely affect health and safety, and provided closet space, over-bed tables, nightstands, privacy curtains, and call lights for each resident. Resident council members stated they had no problem physically getting around their rooms and that nurses were able to provide good care and privacy. The facility policy titled Bedrooms stated that double resident bedrooms must measure at least 80 square feet per resident and single resident rooms at least 100 square feet.
Deficiency in Menu Planning and Nutritional Oversight
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met as outlined in their care plans. These deficiencies were identified through review of facility records and observations, which showed lapses in menu planning, preparation, and oversight by qualified dietary staff.
Failure to Honor Resident Food Preferences
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease (ESRD) and documented dislikes for both pasta and rice was served rice during lunch. The resident's admission record, Minimum Data Set (MDS), and Nutrition/Dietary Note all indicated these food preferences, and the resident's meal ticket for the day in question also reflected the dislike for rice. Despite this documentation, the resident was observed being served rice, and the resident confirmed that rice is regularly served despite staff being aware of the preference. The Registered Dietitian (RD) reviewed the resident's dietary documentation and confirmed that the facility should have honored the resident's preferences and provided an appropriate substitute. The facility's policy requires that food preferences be assessed upon admission and communicated to the interdisciplinary team, with modifications made only with the resident's consent. The failure to follow these documented preferences led to the resident being served an unwanted food item.
Personal Cell Phone Found in Food Preparation Area by Dietary Staff
Penalty
Summary
During an observation in the facility's kitchen, a dietary aide (DA) was found to have her personal cell phone placed in the food preparation area. The DA was seen reaching for her cell phone, which was located on a surface used for food preparation. Upon interview, the DA acknowledged that the cell phone belonged to her and admitted it should not have been in the food preparation area. The Registered Dietician (RD) confirmed during an interview that personal items, including cell phones, must be kept away from food preparation areas to prevent cross-contamination. A review of the facility's policy and procedure on Sanitation and Infection Control indicated that all employee personal belongings, such as clothing, food, and cell phones, should be stored in a separate area away from food or items used in food service. The failure to follow this policy was observed with the DA's cell phone being present in the food preparation area, which did not comply with the facility's infection control and sanitation standards.
Incomplete and Inaccurate Resident Transfer Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by not documenting the correct time on the Resident Transfer Record and by leaving several required sections incomplete. The resident, who had a history of Parkinson's disease, anxiety disorder, and spinal stenosis, was admitted with moderate cognitive impairment and required partial to moderate assistance with daily activities. On the day of the incident, the resident experienced lower abdominal pain, prompting a physician's order for hospital transfer. During the transfer process, the responsible RN documented two sets of vital signs: one at 10:45 a.m. on the SBAR form and another set, taken around 11:45 a.m., on the Resident Transfer Record. However, the RN mistakenly recorded the time as 10:45 a.m. on both documents, resulting in a discrepancy between the actual time the vital signs were taken and the time documented. Additionally, the Resident Transfer Record was found to have several blank sections, including the resident's Social Security Number, insurance information, date and time symptoms were first noted, current diet order, baseline mental status, and possessions transferred. Both the RN and the DON acknowledged the errors and omissions during interviews, confirming that the Resident Transfer Record was incomplete and contained inaccurate information regarding the timing of vital signs. The facility's policy requires that all health records be accurate, timely, specific, and complete, but these standards were not met in this instance.
Failure to Complete Discharge Documentation and Planning
Penalty
Summary
The facility failed to ensure proper discharge planning and documentation for one resident. Specifically, the Discharge Summary did not include a recapitulation of the resident's stay, omitting details about the course of treatment while in the facility. The Post Discharge Plan of Care was incomplete, missing critical information such as the address and phone number of the discharge location, contact information for the discharge and continuing care physicians, the reason for admission and discharge, the resident's mental and psychosocial status, and care preferences. These omissions were confirmed by the Assistant Director of Nursing (ADON) during interviews and record reviews. Additionally, there was no evidence that discharge planning was incorporated into the resident's comprehensive care plan. The ADON acknowledged that a care plan for discharge planning should have been developed to establish goals for the resident's discharge and to involve the interdisciplinary team in supporting those goals. Facility policies reviewed indicated that a complete recapitulation and a comprehensive discharge summary and plan are required to ensure continuity of care and proper adjustment to a new living environment.
Failure to Complete Trauma Care Evaluation for Resident
Penalty
Summary
The facility failed to conduct a trauma care evaluation for one of four sampled residents, despite facility policy requiring universal screening for trauma-informed care. The resident in question was admitted with diagnoses including rhabdomyolysis, dementia, and a history of malignant neoplasm of the breast. Upon admission, the resident had experienced a significant traumatic event, having fallen at home and remained on the floor for approximately five days before being found. The resident's Minimum Data Set indicated intact cognition and dependence on staff for several activities of daily living. During a review of the resident's records, it was found that no trauma care evaluation had been completed. The Social Services Director confirmed that a trauma care evaluation should have been performed for all residents and acknowledged missing this assessment for the resident. The facility's policy on trauma-informed and culturally competent care specifies that universal screening is required to identify the need for further assessment and care, but this was not followed in this case.
Failure to Develop and Implement Comprehensive Care Plans for Pressure Ulcer and Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, specifically regarding the use of low air loss mattresses (LALM) and fall prevention interventions. For two residents with significant pressure ulcers and related risk factors, the care plans did not specify the required LALM setting levels and modes, despite physician orders indicating the need for these specialized mattresses for wound and skin management. Staff interviews confirmed that the care plans lacked individualized details, and the responsible nurse was unable to clarify the appropriate settings, acknowledging the care plans were not comprehensive or person-centered. Additionally, for a resident with a history of falls and multiple neurological and musculoskeletal diagnoses, the care plan included the use of a floor mat (landing mat) as a fall prevention measure. However, during observation, the floor mat was not in place, and the assigned CNA reported not having seen or placed the mat that day. Documentation did not confirm the mat's use, and the DON confirmed that the intervention should have been implemented and monitored by nursing staff, but there was no evidence this occurred. The facility's own policies and procedures require comprehensive, individualized care plans with measurable objectives and timetables, as well as the implementation of physician-ordered interventions. The deficiencies identified were based on direct record review, staff interviews, and observations, demonstrating a failure to ensure that care plans were both comprehensive and implemented as written for residents with complex care needs.
Failure to Notify Physician of Critically Low Blood Sugar Event
Penalty
Summary
The facility failed to notify a resident's physician when the resident experienced a critically low blood sugar level of 45 mg/dl. The resident, who had a history of type 2 diabetes mellitus, morbid obesity, atrial fibrillation, and an above-knee amputation, was admitted with intact cognition and required varying levels of assistance with daily activities. On the date of the incident, a Licensed Vocational Nurse (LVN) administered orange juice as an intervention for the low blood sugar and rechecked the resident's blood sugar 15 minutes later, which had increased to 74 mg/dl. However, the LVN did not document physician notification, and during interviews, it was confirmed that physician notification and documentation were not completed as required. Facility policy required prompt notification of the physician and resident representative for changes in a resident's condition, including hypoglycemic events. The Assistant Director of Nursing (ADON) confirmed that the physician should have been notified and a Change of Condition form completed, regardless of the resident's blood sugar returning to normal after intervention. The facility's policy on diabetes care also specified immediate provider notification for hypoglycemia, which was not followed in this instance.
Failure to Ensure Correct Low Air Loss Mattress Settings for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALM) were set to the correct settings for two residents, both of whom required specialized support surfaces for wound care or prevention of pressure ulcers. For one resident with a history of diabetes and bilateral above-knee amputations, who was severely cognitively impaired and required total assistance, the LALM was observed to be set to static mode rather than the alternating mode as recommended for wound management. Nursing staff had not checked the mattress setting that morning, and the physician's order did not specify the required mode. The treatment nurse confirmed that the alternating mode was necessary to prevent constant pressure on the skin, which could increase the risk of pressure ulcers. For another resident with diabetes and a right femur fracture, who was at risk for pressure ulcers and required maximal assistance, the LALM was found to be set at a weight setting of 280 lbs instead of the recommended 120 lbs based on the resident's body weight. The certified nursing assistant had not checked the setting at the start of her shift and only adjusted it after being prompted. The physician's order for this resident also lacked clarification on the specific setting level or mode, but the treatment nurse confirmed the correct setting should match the resident's weight as posted on the pump unit. Facility policy and the user manuals for the LALM systems indicated that mattress settings should be adjusted according to the resident's weight and clinical needs, and that alternating mode is used to minimize pressure on the skin. The Director of Nursing stated that settings should be individualized for each resident to promote wound healing or prevent skin breakdown, and that failure to follow recommended settings could place residents at risk for further pressure ulcers.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was cognitively impaired and dependent on staff for transfer, toileting, dressing, and bathing, was observed lying in bed with the call light placed underneath her legs, making it inaccessible. The resident had a medical history including seizures, hypothyroidism, and osteoporosis, and required assistance for most activities of daily living. During the observation, a CNA confirmed that the call light should have been within the resident's reach to allow her to call for assistance, and acknowledged that its inaccessibility could delay care. Further interview with the Assistant Director of Nursing corroborated that the call light was not within reach, which could result in delayed response to the resident's needs. Review of the facility's policy indicated that call lights are to be accessible to residents when in bed or in a wheelchair, and the observed situation did not comply with this policy. The deficiency was based on direct observation, staff interviews, and review of facility policy and resident records.
Failure to Knock Before Entering Resident Rooms Compromises Dignity
Penalty
Summary
Facility staff failed to maintain resident dignity and respect by not knocking before entering the rooms of four residents. During an observation, the Infection Preventionist (IP) entered the rooms of these residents without knocking or requesting permission, contrary to facility policy. The IP acknowledged during an interview that she did not knock and recognized the importance of this action in showing respect to residents. The facility's policy on dignity, revised in February 2022, requires staff to knock and request permission before entering a resident's room to promote well-being and self-worth. The residents involved had varying cognitive and physical needs. Two residents had severely impaired cognitive skills and required significant assistance with daily activities, while the other two had intact cognitive skills but still required some assistance with personal hygiene and toileting. The failure to knock before entering affected residents with diagnoses including dementia, intellectual disabilities, epilepsy, cerebral palsy, anxiety, and atrial fibrillation. This practice had the potential to impact the residents' self-esteem and sense of self-worth.
Failure to Develop and Implement Care Plans for Bed Pad Alarm Use in High Fall Risk Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents who were both identified as high fall risks and were observed using bed pad alarms. Both residents had severe cognitive impairment and required substantial to maximal assistance with activities of daily living, as documented in their Minimum Data Set assessments. Despite their high risk for falls, as indicated in their respective Fall Risk Assessments, there was no care plan in place addressing the use of bed pad alarms for either resident. Observations confirmed that both residents were using bed sensor pads connected to alarm monitors, and interviews with nursing staff verified that the alarms were in use due to the residents' high fall risk. However, review of the care plans by the Infection Preventionist revealed that neither resident had a care plan that included interventions or measurable objectives related to the use of bed pad alarms. This lack of care planning was contrary to the facility's own policy, which requires comprehensive, person-centered care plans with measurable objectives and timetables for each resident.
Failure to Secure Medications and Ensure Functionality of Bed Pad Alarms
Penalty
Summary
A deficiency was identified when a resident was found to have multiple bottles of supplements and medications stored at their bedside, accessible to other residents. The resident's care plan noted that the family requested supplements be kept at the bedside, but the resident's assessment indicated they were not safe to self-administer medications and required staff assistance for all medication administration. Despite this, the medications were left in a plastic bag at the bedside, and both the Director of Social Service and the DON confirmed the presence of these medications. Facility policy required that medications be stored securely and only accessible to authorized personnel, which was not followed in this instance. Additionally, the facility failed to ensure daily checks and documentation of the functionality of bed pad alarms for two residents identified as high fall risks. Both residents had severe cognitive impairment and required substantial assistance with daily activities. Observations confirmed that both residents were using bed pad alarms, but staff were unable to demonstrate or document that the alarms were checked for proper functioning as required by facility policy. Interviews with nursing staff and the DON revealed a lack of clarity on where or how the checks were to be documented, and in one case, a nurse stated the alarm was not functioning. The facility's policies required that personal alarms be checked daily for proper functioning and that nursing staff monitor and document their status. However, record reviews for both residents did not show any evidence that these checks were performed or documented. This lack of adherence to policy and procedure resulted in a failure to provide an environment free from accident hazards and adequate supervision to prevent accidents for the residents involved.
Expired First Aid Kit and Unattended Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure proper storage and timely removal of expired drugs and biologicals, as evidenced by the presence of an expired first aid kit in the medication storage room. During an inspection, a registered nurse confirmed that the first aid kit had expired and acknowledged that licensed staff are required to immediately remove expired items from the medication storage area. The Director of Nursing also confirmed that nurses are expected to inspect the medication storage room every shift and remove expired medications and supplies, but an expired kit was still present during the survey. Additionally, a medication cart was observed left unlocked and unattended in a hallway, with staff walking by the unsecured cart. The licensed vocational nurse responsible for the cart admitted to leaving it unlocked while retrieving a binder, despite facility policy requiring medication carts to be locked when unattended. The Assistant Director of Nursing confirmed that medication carts should always be locked when not attended by authorized personnel. Facility policy states that medications and biologicals must be stored securely and only accessible to authorized staff.
Multiple Lapses in Infection Control and PPE Use
Penalty
Summary
Facility staff failed to maintain proper infection prevention and control practices in several instances. In one case, a treatment nurse provided wound care to a resident on enhanced barrier precautions due to a sacrococcyx pressure sore and exited the resident's room while still wearing an isolation gown. Both the infection preventionist and the director of nursing confirmed that the gown should have been removed before leaving the room, as per facility policy and standard infection control practices. In another instance, a resident on droplet isolation for COVID-19 exposure did not have a trashcan inside the room, making it impossible for staff or visitors to properly doff and dispose of personal protective equipment (PPE) before exiting. The director of social services, infection preventionist, and director of nursing all acknowledged that a trashcan is required inside such rooms to prevent the spread of infection. Additionally, a resident's nasal cannula oxygen tubing was observed lying on the floor, which was recognized by staff as a contamination risk, and the tubing was immediately discarded. Further deficiencies included two residents whose urinals were not labeled with their identifiers, creating a risk of cross-contamination if the urinals were accidentally switched. Staff confirmed that urinals should be labeled with the resident's initials, room, and bed number. Lastly, a certified nurse assistant entered a room under respiratory precautions for COVID-19 exposure without wearing a gown, contrary to posted signage and facility policy, which required full PPE for anyone entering the room.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents who required assistance with activities of daily living. For one resident with end stage renal disease, heart failure, and bipolar disorder, the care plan specifically indicated that the call light should be within easy reach due to the resident's moderate cognitive impairment and need for moderate to maximal staff assistance. However, during an observation, the call light was found hanging under the bed and not accessible to the resident. A CNA confirmed that the resident could not reach the call light, which could result in delayed care. Similarly, another resident with hypertensive chronic kidney disease, major depression, and essential hypertension, who also had severely impaired cognition and required maximal assistance, was observed lying in bed with the call light located on the wall and out of reach. The resident stated she could not reach the call light, and the CNA acknowledged the risk of delayed care if the resident was unable to call for assistance. The facility's policy required that a means to call staff for assistance be provided, but this was not followed in these cases.
Incomplete Baseline Care Plan for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had an indwelling catheter. Upon review of the resident's admission records, assessments, and physician orders, it was found that although the baseline care plan noted the presence of an indwelling catheter, it did not include any nursing interventions or instructions for the care and monitoring of the catheter. The resident had diagnoses including type 2 diabetes mellitus, obstructive uropathy, and reflux uropathy, and required substantial to maximal assistance with activities of daily living. Physician orders specifically indicated the need for daily catheter care, but this was not reflected in the baseline care plan. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the baseline care plan was incomplete and did not address the required interventions for the resident's catheter. The facility's policy requires that a baseline care plan be developed within 48 hours of admission to address immediate health and safety needs, including all necessary services and treatments. The omission of catheter care interventions in the baseline care plan constituted a failure to meet this requirement for the resident.
Failure to Rotate Subcutaneous Injection Sites for Anticoagulant Administration
Penalty
Summary
The facility failed to ensure that subcutaneous injection sites were rotated for a resident receiving anticoagulant therapy, specifically Enoxaparin Sodium (Lovenox), as required by professional standards of practice. Review of the resident's Medication Administration Record (MAR) for March and April showed that injections were consistently documented as being administered in the abdomen, without specifying the exact area or indicating rotation of sites. This practice was confirmed during an interview with a registered nurse, who acknowledged that proper documentation and rotation of injection sites are necessary to prevent tissue damage and discomfort. The resident involved had a history of muscle weakness, COPD, and hypertension, and required staff assistance with activities of daily living. The resident's cognitive skills for daily decision-making were intact. Physician orders directed daily subcutaneous administration of Lovenox for deep vein thrombosis prophylaxis. Manufacturer instructions provided by the facility also specified alternating injection sites between the left and right sides of the abdomen. Despite these guidelines, the facility's documentation and practice did not reflect adherence to site rotation protocols.
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
A deficiency was identified when a resident whose primary language was Arabic and who had severely impaired cognitive skills was not provided with a communication board to assist with communication. The resident required substantial to maximal assistance with activities of daily living, including eating, oral hygiene, toileting hygiene, and personal hygiene. The resident's care plan noted a risk for unmet needs due to communication difficulties and specified that the resident's main language was Arabic. However, during observation and interviews, staff were unable to locate a communication board at the resident's bedside, and a nurse was not aware of the resident's primary language. The Director of Nursing confirmed that staff should use a communication board to facilitate communication with the resident, especially given the language barrier. The facility's policy required meaningful access to information and services for individuals with limited English proficiency. Despite this, the lack of a communication board at the bedside prevented staff from effectively communicating with the resident, which could have delayed the resident's care and treatment.
Failure to Provide Ordered Oxygen Therapy and Maintain Oxygen Equipment
Penalty
Summary
The facility failed to ensure that residents received continuous oxygen therapy as ordered by their physicians for two of five sampled residents. One resident with a history of acute respiratory failure, hypoxia, and COVID-19 was observed without an oxygen machine at bedside, despite a physician's order for continuous oxygen at three liters per minute via nasal cannula. The resident confirmed not using oxygen recently, and staff interviews revealed that the physician's order was not followed, with no documented reason for discontinuation or physician notification. Another resident with acute respiratory failure and COPD was also found not wearing the prescribed nasal cannula during observation, despite an active order for oxygen therapy. Additionally, the facility did not ensure that oxygen tubing was dated and changed according to facility policy and physician orders for two residents. One resident's oxygen tubing and bag were observed to be undated, and staff confirmed that the tubing should have been dated and replaced weekly. Another resident's oxygen tubing and bag were found to be dated beyond the required seven-day change interval, indicating the tubing had not been replaced as scheduled. Staff interviews confirmed that central supply was responsible for changing and dating the tubing, and that the failure to do so was not in accordance with facility policy. Record reviews and staff interviews consistently indicated that the facility's policies required oxygen to be administered as ordered by the physician and for oxygen equipment to be dated and changed at specified intervals. Observations and documentation showed that these requirements were not met for multiple residents, with staff acknowledging the lapses in following physician orders and facility protocols for respiratory care and infection prevention.
Failure to Implement Fluid Restriction Order for Dialysis Resident
Penalty
Summary
The facility failed to implement a physician's order for fluid restriction for a resident with end stage renal disease who was dependent on hemodialysis. The physician's order, dated 1/28/2025, specified that the resident should be on fluid restriction and that no water pitcher should be placed at the bedside. Despite this, during an observation on 4/27/2025, a full pitcher of water, a full glass of water, and another half-full glass of water were found on the resident's side table. The resident confirmed awareness of the fluid restriction and stated that water was only consumed with morning medications. Staff interviews confirmed knowledge of the physician's order and acknowledged that the order was not followed, as water was present at the bedside. The Director of Nursing also confirmed that staff are required to implement physician orders for fluid restriction, particularly for residents undergoing hemodialysis. Review of facility policy indicated that fluid restriction orders limiting water at the bedside should be followed as directed by the attending physician.
High Medication Error Rate Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a medication error rate of 32.14 percent. This was identified during observation, interview, and record review, where nine medication errors were found out of 28 opportunities, all involving a single resident. The errors consisted of administering nine different medications at times different from those ordered by the physician. The resident involved had a history of difficulty walking, depression, dysphagia, and falls, and was assessed as having moderately impaired cognitive skills, requiring partial to moderate staff assistance for daily activities. The resident was prescribed multiple medications, including anastrazole, bupropion, carvedilol, furosemide, sertraline, vitamin C, thiamine, a multivitamin with minerals, and magnesium oxide, all scheduled for administration at specific times, primarily at 9:00 a.m. and 5:00 p.m. On the day of the observed deficiency, a nurse prepared and administered the resident's morning medications at 11:24 a.m., well past the scheduled 9:00 a.m. administration time and outside the facility's one-hour window policy. The nurse acknowledged being late due to being busy with other residents and confirmed that administering medications outside the prescribed time frame is considered a medication error. The facility's policy requires medications to be administered within one hour of the prescribed time unless otherwise specified.
Failure to Label and Store Leftover Food Brought by Visitors
Penalty
Summary
The facility failed to ensure that leftover food brought in by family or visitors for two residents was properly labeled with the resident's identifier and a use by date, as required by facility policy. In the case of one resident with chronic kidney disease and hypertension, who was cognitively intact and independent in activities of daily living, two containers of food brought by a family member were found on the overbed table without any labeling. The resident confirmed the food was brought the previous day. A registered nurse acknowledged that the food should have been labeled and refrigerated according to policy, but this was not done. Similarly, another resident with chronic kidney disease and hypertension, who required assistance with activities of daily living but was cognitively intact, had a box of pizza left on the overbed table, also brought by a visitor the previous day. This food was not labeled or refrigerated as required. The registered nurse confirmed that the leftover pizza should have been labeled with the resident's name and use by date and refrigerated to prevent spoilage, in accordance with the facility's policy. Both instances were observed and confirmed through interviews and record reviews.
Failure to Meet Minimum Room Size Requirements for Multiple-Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 26 out of 40 multiple-resident rooms, as required by federal and state regulations. During a recertification survey, it was found that several rooms, including those with two to four beds, did not meet the minimum square footage per resident. The room sizes ranged from 72 to 79 square feet per resident, which is below the required 80 square feet for multiple-resident rooms. The deficiency was identified through observation, interviews, and record review, including a review of the facility's room variance waiver application and supporting documentation. Despite the deficiency in room size, observations and resident interviews indicated that residents had sufficient space to move freely, and staff were able to provide care and maintain privacy. Residents reported no issues with mobility or receiving care in their rooms, and each room was equipped with privacy curtains, call lights, and adequate storage. The facility's policy stated that bedrooms should meet the required square footage, but the actual measurements in the identified rooms did not comply with these standards.
Failure to Conduct Psychosocial Assessments and Follow-Up Calls
Penalty
Summary
The facility failed to ensure that the social services department conducted psychosocial assessments upon admission for two residents and did not make follow-up calls to three residents after they were discharged home. This deficiency was identified during interviews and record reviews, revealing that the facility did not adhere to its policy of providing medically related social services to help each resident achieve the highest possible quality of life. Resident 1 was admitted with a non-displaced fracture of the right femur, a history of falling, and difficulty walking. The resident's cognition was severely impaired, requiring assistance with daily activities. Despite being discharged home with a 24-hour caregiver, there was no documented evidence of a follow-up call to ensure the resident's safe transition home. The Social Services Director (SSD) acknowledged the oversight and the absence of discharge documentation. Similarly, Resident 2, admitted with metabolic encephalopathy and other conditions, did not receive a psychosocial assessment upon admission, and no follow-up call was made after discharge. Resident 3, admitted with fractures and muscle weakness, also lacked a psychosocial assessment and follow-up call post-discharge. The SSD admitted to these deficiencies, recognizing the importance of such assessments and follow-up calls for resident safety and adjustment post-discharge.
Failure to Document Physician Notification for Elevated Apical Pulse
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a history of atrial fibrillation, a cardiac pacemaker, and type 2 diabetes. The resident was readmitted to the facility with a physician's order to monitor the apical pulse daily and notify the physician if the pulse was less than 60 or greater than 100 beats per minute (bpm). On multiple occasions, the resident's apical pulse exceeded 100 bpm, but the facility did not document efforts to notify the physician as required. Licensed Vocational Nurse 1 (LVN 1) was responsible for monitoring the resident's apical pulse and acknowledged that the pulse exceeded 100 bpm on several dates. Although LVN 1 stated that she called the physician, she failed to document these calls in the resident's medical record. The facility's policy on charting and documentation requires that all services provided, progress toward care plan goals, and changes in the resident's condition be documented to facilitate communication among the interdisciplinary team. The lack of documentation placed the resident at risk of not receiving appropriate care due to incomplete medical records.
Unnecessary Administration of Ivermectin
Penalty
Summary
The facility failed to ensure there was an adequate indication for the use of ivermectin for a resident who was not diagnosed with scabies. The resident, who was readmitted to the facility with diagnoses including atrial fibrillation, presence of a cardiac pacemaker, and type 2 diabetes, was administered ivermectin for a body rash. However, there was no documented evidence that the resident had scabies, which is a condition that ivermectin is typically used to treat. The medication was administered on two consecutive days, despite the absence of a scabies diagnosis. During a review of the resident's medical records and a concurrent interview with the Infection Preventionist, it was confirmed that ivermectin was administered without a proper diagnosis of scabies. The Infection Preventionist acknowledged that the medication should not have been given, as the resident did not have scabies. The report highlights that the use of ivermectin in this case was unnecessary and could potentially lead to adverse side effects.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure that licensed nurse staff completed the reconciliation of controlled medications for one of four medication carts, specifically Medication Cart A. This process is crucial for validating that the amount of controlled substances, which have a high potential for abuse, at the end of a shift matches the expected amount. During an interview and record review, it was found that there were gaps in the Controlled Drugs Accountability Sheet (CDAS) for November and December 2024, where two licensed nurses did not sign off on the reconciliation process on multiple dates. Licensed Vocational Nurse 2 (LVN 2) acknowledged these gaps and stated that while they always counted the medications with another nurse, they could not confirm if the medications were counted but not signed for, or if they were not counted at all. The Director of Nursing (DON) confirmed that the facility's protocol requires both the outgoing and incoming licensed nurses to count the controlled medications together and sign the CDAS form. Any discrepancies should be reported immediately to the DON for further investigation. The facility's policy and procedure on controlled substances, last reviewed in April 2024, mandates compliance with all relevant laws and regulations, including the reconciliation of controlled substances at the end of each shift. The failure to adhere to these protocols had the potential to result in inaccurate reconciliation and placed the facility at risk for drug diversion and loss of controlled medications.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which is a critical aspect of accommodating the needs and preferences of residents. Resident 1, who was admitted with severe cognitive impairment and required total assistance for daily activities, was found with a call light that was stuck on the left side of the bed frame, making it inaccessible. This was observed during an interview with an LVN, who acknowledged the issue and repositioned the call light within reach. The resident's care plan had specified that the call light should be attached to the bed within the resident's access, but this was not adhered to. Similarly, Resident 2, who also had severe cognitive impairment and required maximum assistance, was observed sitting in a geriatric chair with the call light tangled and out of reach. This was confirmed by a CNA and later by an LVN, who untangled and repositioned the call light. The resident's care plan also indicated that the call light should be within reach, and the facility's policy required that residents be provided with a means to call for assistance. The Assistant Director of Nursing confirmed that staff should ensure call lights are accessible when leaving residents' rooms.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
