Miracle Mile Healthcare Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 1020 South Fairfax Ave, Los Angeles, California 90019
- CMS Provider Number
- 555139
- Inspections on file
- 86
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 41
Citation history
Health deficiencies cited at Miracle Mile Healthcare Center, Llc during CMS and state inspections, most recent first.
A resident with cardiac conditions and left-sided hemiplegia was inaccurately coded on the MDS regarding functional status and need for assistance with ADLs and mobility. The MDS nurse’s assessment documented the resident as needing setup and supervision/touching assistance for eating, dressing, transfers, and walking, while an LVN and the DON both described the resident as independent in ADLs, ambulating with a steady gait, and not requiring setup help with meals. This discrepancy, despite facility policies requiring accurate, objective MDS completion and documentation, resulted in an inaccurate assessment of the resident’s status.
A resident with COPD, HTN, anemia, major depressive disorder, failure to thrive, and muscle weakness experienced a change in condition with an SpO2 of 86%. An LVN reported that a physician ordered and staff applied a nonrebreather mask with oxygen, but this intervention was not documented in the Change of Condition note or transfer form. This omission conflicted with facility policies requiring complete, accurate charting of all changes in condition and treatments provided.
Two residents, one cognitively intact and wheelchair‑dependent and another with moderate cognitive impairment and agitated behavior, were involved in an altercation after independently accessing a hallway coffee cart containing large insulated containers of hot coffee and hot water. The cognitively intact resident reported waiting at the cart, then leaving for the smoking area, where staff later walked the cognitively impaired resident; the latter allegedly threw hot coffee onto the first resident’s face while nearby staff reportedly laughed and did not provide remembered first aid. Staff interviews confirmed that residents typically poured their own hot beverages from the unattended cart, that the cognitively impaired resident was forgetful, frequently ambulated, and could become combative, and that such unsupervised access to hot liquids by confused or agitated residents posed a burn hazard, contrary to the facility’s own supervision policy.
Failure to maintain ROM and mobility affected multiple residents with significant neurologic and functional impairments. One resident’s RNA AROM program was not carried out as ordered, another resident’s PT eval lacked objective ROM measurements, and three residents were placed on RNA splinting programs without prior PT/OT evaluation and treatment to assess fit and safe wear time. A separate resident’s joint mobility assessment showed worsening wrist ROM, but the program was not adjusted after the decline was identified.
A facility failed to document and report repeated medication refusals for a resident with schizoaffective disorder and epilepsy, failed to follow seizure and medication administration policies for another resident who repeatedly refused Keppra and received Metformin without food, and failed to tell a third resident what medications were being administered during med pass. Staff and the DON acknowledged the refusals, the missed documentation, and the medication administration issues.
Failure to follow standardized texture-modified recipes during meal service: minced and moist bread, cabbage, and carrots were prepared in pieces larger than required, and corned beef for residents on a soft and bite size diet was served minced instead of chopped to 1/2-inch pieces. Staff acknowledged the recipes were not followed, and the DS stated the correct texture and recipe should always be used.
Unsafe food storage, sanitation, and labeling practices were observed in the kitchen and resident areas. Expired or improperly stored foods were found in the walk-in refrigerator, cooked food was stored below raw meat, the grease trap area had standing water with an oily substance, and a can opener blade was dirty and worn. The resident refrigerator lacked a current temp log and contained unlabeled or expired items, and a resident had undated condiment cups of lime juice at bedside.
Unsanitary Dumpster Area With Open Bins and Scattered Trash: The facility failed to keep the dumpster area sanitary when three of four trash bins were overfilled, lids were left open, flies were present, and trash was scattered on the ground and under the bins. During observation and interview, the MS and DS acknowledged the open lids and debris in the area, and the facility policy required trash to be sealed, lids closed, and the area kept clean.
A resident with a triple lumen PICC for TPN had a dressing observed with conflicting change dates, including one dated earlier beneath a newer sticker, while staff stated PICC dressings are changed every 7 days and as needed. The facility also could not locate N95 fit test records for three sampled staff members, even though the IP and DON stated fit testing is done upon hire and annually to ensure proper respirator fit and reduce infection spread.
Unassessed bedside medication storage: A resident with multiple medical diagnoses had two prefilled normal saline syringes left unattended in a bedside drawer without a documented assessment of cognitive and physical ability for self-administration. An LVN did not know who placed the syringes there, an RN stated they should not be left unattended at bedside, and the DON said bedside meds require assessment, physician approval, and secure storage.
A contracted PTA with a court conviction for corporal injury remained on the rehab staff schedule and was observed working in the rehab gym. The DOR knew of the citation on the PTA’s PTBC license, and the DSD later confirmed the citation involved a misdemeanor for corporal injury but relied on the DOR’s assurance that the PTA could keep working. The facility’s abuse policy stated it does not employ anyone found guilty of abuse or mistreatment by a court of law.
Failure to Provide Written Bed-Hold Notification: A resident with PVD, HTN, and HLD was cognitively intact and required assistance with ADLs, but the bed hold informed consent had blank sections for transfer and bed-hold confirmation and 24-hour notification. An LVN stated the blank sections indicated the resident was not notified of the bed hold, and the DON stated written notification should be provided to the resident or representative before transfer and discharge to the hospital.
Failure to provide SLP services for a resident with CVA-related dysarthria and anarthria. The resident had unclear speech, could usually make self understood, and had a care plan addressing communication problems, but staff observed the resident could answer simple questions only part of the time and could not use a communication book effectively. Interviews with the DOR, SLP, SSD, MDS coordinator, and DON confirmed the resident never received SLP services at the facility despite significant communication deficits and frustration with communication.
Wheelchair Missing Required Hand Brake: A resident with muscle wasting/atrophy, OA, and asthma was identified as a fall risk and unable to walk, yet was provided a wheelchair without a second hand brake. The resident stated she was scared of falling, and the DOR and DON both confirmed the wheelchair needed two hand brakes for safety when getting in and out of the chair.
Failure to Obtain Ordered Pain Consultation: A resident with chronic back pain, paraplegia, and stage 4 buttock pressure ulcers had a pain care plan and pain meds ordered, but the facility did not arrange the ordered stat pain consult. The resident reported ongoing stabbing pain that was not relieved by the current regimen, an LVN confirmed the consult was never completed, and the pain consultant MD said he was never contacted about the referral.
Failure to Document Target Behaviors for Psychotropic Medications: A resident with paranoid schizophrenia and schizoaffective disorder was prescribed Haldol and Risperdal for specific behavioral symptoms, but staff did not document the targeted behaviors on the MAR as ordered. The record included an SBAR for severe agitation requiring law enforcement involvement and a hospital transfer, while observations showed the resident talking to self, laughing, smiling, and pacing. RN, LVN, and DON statements confirmed that target behaviors such as agitation, yelling, pacing, and anxiety should have been documented and tallied for review.
Pharmacist Failed to Identify Repeated Keppra Refusals During Monthly Drug Review. A resident with epilepsy and intact cognition repeatedly refused Keppra, including 126 refusals over several months, while the MAR showed no seizure activity. The consultant pharmacist stated she did not regularly review the MAR, was unaware of the repeated refusals, and did not send any recommendations to the physician or document irregularities during monthly DRR/MRR.
Medication Given Outside Ordered Pain Parameters: A resident with intact cognition and multiple medical diagnoses was given Norco for pain that was documented as 3/10, even though the MD order allowed the medication only for severe pain of 8-10/10. The DON confirmed the medication was administered outside the ordered parameters, and an LPN stated she did not remember the resident’s pain score before giving the dose and would not have given Norco for a pain level of 3.
Improper Medication Labeling and Storage: An open box of BG control solution was found in a med cart without an open date, even though the manufacturer stated it expires 3 months after opening. In addition, medications labeled for a resident who had already been transferred out of the facility were still stored in another med cart. The LVN and DON stated discontinued meds should not remain in the cart, and facility policy required incomplete labels and discontinued drugs to be removed from storage or returned to the pharmacy.
Loose Bed Grab Bar Not Maintained: A resident with dementia, cognitive impairment, and mobility needs had a left bed grab bar observed to be insecurely fastened and unstable. An LVN stated the grab bar was loose and missing a bolt, and the resident used the grab bars to balance and walk. The DON stated staff were responsible for identifying broken equipment and notifying maintenance, and facility policy required hazardous equipment and bed safety issues to be identified and addressed.
A facility failed to provide at least 80 sq. ft. of usable living space per resident in 30 of 38 rooms. The Administrator submitted a room size waiver letter stating the rooms did not compromise privacy, storage, ambulation/wheelchair access, toilet accessibility, or space for nursing care. The accommodations analysis showed multiple 2-, 3-, and 4-bed rooms measuring below the required minimum, although observations noted residents had ample space to move freely and the rooms had space for beds, side tables, and care equipment.
A resident with incontinence, impaired mobility, and communication deficits related to a prior stroke was not assigned a CNA on an overnight shift, despite needing partial assistance with toileting and transfers. As a result, the resident was not checked for several hours and was later found by an LVN sitting on the floor in feces. CNAs cleaned the resident while the resident remained on the floor but were unable to lift the resident back to bed, and the RN supervisor did not assist before the end of the shift. The resident remained on the floor until the next shift arrived to complete the transfer, and leadership was not promptly notified, contrary to facility abuse/neglect policies.
A resident with complete paraplegia and high dependence for ADLs was care planned and ordered to use a low air loss (LAL) mattress for skin impairment prevention, with nursing staff required to monitor its placement and functioning each shift per the manufacturer’s Dynarex manual. During an observation, an LVN responding to a call light found the LAL mattress alarm sounding and the low-pressure indicator flashing, and discovered the mattress was incorrectly set at 350 lbs instead of the resident’s actual weight of 106 lbs. The LVN stated the treatment nurse was responsible for verifying correct settings, and the DON acknowledged that an incorrectly set LAL mattress can adversely affect skin management and pressure injury prevention.
A resident with incontinence, impaired mobility, OA, and a high fall risk had care plans requiring q2h checks for toileting, prompt response to assistance requests, and use of floor mats for safety. On an overnight shift, no CNA was assigned to the resident due to an error on the CNA assignment sheet, and the charge LVN did not make rounds until early morning, when the resident was first found on the floor. Later, CNAs found the resident still on the floor, sitting in feces, and were unable to lift the resident, who remained there until the next shift arrived. Leadership was not notified of the fall or the assignment error, no timely investigation was initiated as required by facility policy, and an observation on a later date showed that ordered floor mats were not in place in the resident’s room.
A resident with paraplegia, intact cognition, and dependence on staff for toileting and most ADLs was left in the same incontinent brief for approximately three days, despite a care plan requiring brief changes every two hours and as needed with perineal cleansing after each incontinence episode. A CNA had dated and initialed the brief when it was applied due to concern that staff were not changing the resident as required, and upon returning from days off, found the same brief still in place. This failure to follow the resident’s care plan and facility policies on ADLs and fecal incontinence resulted in the resident remaining soiled for an extended period, which the DON stated increased risk for skin breakdown and compromised dignity.
A resident with dementia and psychiatric disorders, known for exit-seeking and aggressive behaviors, was not properly assessed for elopement risk and did not have an updated care plan or adequate supervision. Despite multiple episodes of exit-seeking, staff failed to provide continuous 1:1 monitoring, resulting in the resident breaking a window and sustaining serious leg fractures that required hospitalization and surgery. Staff interviews revealed lapses in assessment, supervision, and documentation, as well as allegations of pressure to falsify incident reports.
A resident with a history of mental health disorders exhibited escalating aggressive and erratic behavior, including attempts to elope and physical aggression. Despite staff reporting these behaviors, the response was limited to medication administration without hospital transfer. The resident subsequently broke a window, fell, and sustained severe leg fractures, requiring emergency hospital care. Another resident in the same room reported feeling unsafe and disturbed by the incident.
A resident with multiple medical conditions was placed in a room with a broken window, resulting in exposure to cold temperatures for two days. The window was not repaired promptly, extra blankets were not provided, and the resident was not moved to another room. Staff confirmed incomplete temperature logs and lack of timely maintenance, contrary to facility policy.
A window in a resident room was observed open with a large hole in the screen, allowing insects to enter. A CNA and the infection preventionist confirmed that the damaged screen permitted flies and mosquitoes into the room, contrary to facility policy requiring a safe and sanitary environment.
A resident who was cognitively intact and required moderate assistance with ADLs was unable to reach the call light, which was found on the floor and out of reach. The resident reported calling for help for several hours without response, and staff confirmed the call light was not accessible as required by facility policy.
A resident with multiple chronic conditions requiring significant assistance was observed wearing soiled clothing and lacking proper incontinence care, with personal items and linens left unclean. The resident expressed feelings of embarrassment and neglect, and staff confirmed that the resident's dignity and rights were not upheld according to facility policy.
A facility failed to develop a care plan for a resident with memory problems, despite the resident's admission record indicating severe cognitive impairment and a history of memory issues. The resident required assistance with activities of daily living, and an LVN confirmed that a care plan should have been created. The facility's policy mandates comprehensive care plans, but this was not implemented for the resident.
A facility failed to ensure timely physician visits for a resident with complex medical conditions, as required by regulations. The resident, with diagnoses including schizophrenia and diabetes, did not receive face-to-face visits from the attending physician after a certain date, despite facility policy requiring regular visits. This was confirmed through interviews and record reviews, revealing a lapse in adherence to the required visit schedule.
A resident missed a medical appointment due to the facility's failure to arrange timely transportation. Despite notifying staff two weeks in advance, the transport arrived late, leading to the appointment's cancellation. The DSS admitted the issue could have been avoided with prior confirmation of transportation arrangements.
A cognitively impaired resident in an LTC facility was not provided with the required 80 square feet of living space in a shared room. The resident's space was reduced to 48.44 square feet due to another resident's belongings encroaching on their area. The Maintenance Director and Facility Administrator confirmed the deficiency, acknowledging the potential impact on privacy, dignity, and safety.
A facility failed to address a persistent ceiling leak in a room occupied by two residents, creating a fall risk due to water accumulation on the floor. Despite multiple repair attempts, the leak continued, and the residents were not relocated. Staff acknowledged the safety hazard, but only temporary measures were taken, contrary to the facility's policy of maintaining a hazard-free environment.
The facility failed to maintain a safe environment by not addressing water leaks in a room occupied by two residents, leading to potential safety hazards. Despite reports of the issue, the residents were not relocated, and repairs were unsuccessful. Additionally, a malfunctioning thermostat affected temperature control in multiple rooms, potentially compromising residents' health and comfort.
The facility's elevator was frequently malfunctioning, causing staff to get stuck and requiring frequent resets by a Monitor Aide. The issue, known to the Maintenance Supervisor, Administrator, and Nursing Supervisors, had persisted for at least a year. An urgent inspection was conducted, but repairs had not been made. The facility's maintenance policy requires equipment to be safe and operable, which was not met.
The facility failed to document advance directives for three residents, potentially conflicting with their healthcare wishes. Despite having intact or moderately impaired cognition, these residents did not have advance directives in their medical records. The absence of these documents was confirmed by staff, highlighting a failure to adhere to the facility's policy requiring completion within 72 hours of admission.
The facility failed to properly store and dispose of controlled and non-controlled medications, as required by its policy. Expired medications were destroyed by night shift nurses instead of the DON, and the storage container for narcotics was not securely locked. The facility also lacked proper records of medication disposal, contrary to its policy.
The facility was found deficient in maintaining safe food storage and preparation practices. Personal items were placed on a prep sink, hashbrowns in the freezer were not labeled with open dates, and a Dietary Aide failed to wash hands between handling dirty and clean dishes, risking cross-contamination. The DON highlighted the importance of labeling to prevent serving expired foods.
The facility failed to maintain an industrial washing machine, essential for providing clean linen to 111 residents. One of two machines was out of service for a month, with no part ordered or repair scheduled, potentially delaying linen delivery and causing resident frustration.
The facility failed to obtain informed consent from two residents before starting psychotropic medications. One resident had moderate cognitive impairment, while the other had intact cognition. In both cases, consent forms lacked the residents' signatures and proper verification by a nurse, violating facility policy.
A resident was left feeling uncomfortably cold in bed without adequate coverings due to the facility's failure to provide a homelike environment. The resident, who was cognitively intact and required assistance with daily activities, was observed without a top sheet, blanket, or pillowcase. A CNA removed the linen in the morning but did not replace it due to a lack of clean linen available. The DON confirmed the importance of a homelike environment, which includes having a fully made bed with clean linen.
A resident with cerebral palsy and muscle wasting did not receive adequate assistance with ADLs, such as bathing and toileting, due to staff inaction and lack of documentation. The resident reported long waits for care and was left in soiled conditions, while the facility's policy required assistance for those unable to perform ADLs independently.
A facility failed to provide proper colostomy care for a resident, resulting in skin excoriation and potential infection risk. The resident, admitted with colostomy malfunction, reported that their colostomy bag was not changed as needed, leading to skin irritation. An LVN confirmed the issue, and the Treatment Nurse noted that timely changes were necessary to prevent skin breakdown and infection. The facility's policy aimed to prevent skin exposure to fecal matter, but it was not followed in this instance.
A facility failed to complete post-hemodialysis assessments for a resident with ESRD, who required dialysis services. The resident's care plan included monitoring vital signs and reporting signs of infection at the access site. However, post-dialysis assessments were missing on several occasions, and there were no progress notes documenting these assessments. The DON acknowledged that this failure could result in not addressing changes in the resident's health condition.
A facility failed to ensure the retrieval of a resident's personal belongings from a previous skilled nursing facility. The resident, with multiple health conditions, expressed frustration over the lack of assistance from the social service designee, who was unable to provide documentation or specific details about the belongings' transfer. This oversight had the potential for the resident's property to be misplaced or lost.
The facility staff failed to follow infection control protocols, with a clean bedside table, linen, and wheelchair improperly stored in a resident's bathroom, and an LVN exiting a room with gloves and medication in hand. These actions risked cross-contamination and infection spread.
A resident in the facility was found to have a broken trim, missing closet knobs, and an exposed wire in their room, which were present upon admission. The Maintenance Assistant confirmed these issues and noted a lack of guidance following the recent resignation of the Maintenance Supervisor. The resident, who has mild cognitive impairment and requires assistance with daily activities, expressed frustration over the unaddressed repairs.
Inaccurate MDS Coding of Resident Functional Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for one resident. The resident was admitted with diagnoses including bradycardia, hypertensive heart disease with heart failure, cardiomyopathy, and left-sided hemiplegia. An MDS dated 4/1/26 documented the resident as having intact cognition. During a concurrent interview and record review on 4/16/26, the MDS assessment showed the resident as independent for self-care, indoor mobility, stairs, and functional cognition, but also coded as requiring setup or clean-up assistance with eating and upper body dressing, and supervision or touching assistance with other ADLs and mobility tasks such as sit-to-stand, chair-to-stand, toilet transfer, and walking 10 feet. The MDS nurse stated she completes assessments at the bedside, acknowledged the discrepancy between coding the resident as independent and then as needing assistance, and asserted that her assessment indicating the resident needed assistance was correct, further stating that all residents need assistance or they would not be in the facility. In contrast, during an interview outside the resident’s room, an LVN reported that the resident was independent in all ADLs, ambulated down the hall with a steady gait, did not require setup assistance with meals, and independently managed eating, dressing, and toileting. The DON also stated that the resident was known to be independent for ADLs and walking and did not know why the MDS was coded to show the resident as needing assistance, noting that the MDS nurse was new and might need training. Review of facility policies on Electronic Transmission of MDS and Charting and Documentation indicated that all MDS assessments must be completed and encoded into the facility’s MDS system, staff are to be trained on MDS updates, and all services and changes in a resident’s condition must be documented objectively, completely, and accurately. The discrepancy between staff observations and the MDS coding demonstrated that the facility did not ensure the accuracy of the resident’s MDS assessment.
Failure to Document Oxygen Intervention During Change of Condition
Penalty
Summary
The facility failed to document an intervention performed during a change of condition for one resident, resulting in an incomplete medical record. The resident was admitted with multiple diagnoses, including COPD, HTN, anemia, major depressive disorder, failure to thrive, and muscle weakness. The resident’s History and Physical indicated a lack of decision-making capacity, and the MDS documented short- and long-term memory problems, severely impaired daily decision making, and a need for substantial to total staff assistance with ADLs and bed mobility. During a review of the resident’s Change of Condition progress note and Facility Transfer Form, surveyors noted that neither document contained any record of an intervention for a documented low SpO2 of 86%. In an interview and concurrent record review with an LVN, the LVN confirmed that there was no documentation of the intervention for the low oxygen saturation. The LVN stated that a physician was present during the incident and ordered a nonrebreather mask with oxygen, which was applied to the resident, but this treatment was not recorded in the medical record. Facility policies on “Change in a Resident’s Condition or Status” and “Charting and Documentation” required that all changes in condition and all treatments or services provided, including care-specific details and how the resident tolerated the treatment, be documented in the medical record. The absence of documentation for the oxygen intervention during the resident’s change of condition was therefore not in accordance with the facility’s policies and accepted professional standards for maintaining complete and accurate medical records.
Inadequate Supervision of Hot Beverage Cart Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and monitoring for cognitively impaired ambulatory residents in accordance with its Safety and Supervision policy. The facility allowed residents, including a moderately cognitively impaired and sometimes combative resident, to independently access a coffee cart containing large insulated containers of hot coffee and hot water (175–180°F) that was parked in the hallway in front of the nursing station. Staff interviews confirmed that residents typically poured their own hot beverages from this cart and that there was uncertainty about who, if anyone, assisted or supervised the cognitively impaired resident when he obtained his coffee. One resident involved in the incident was non‑ambulatory, wheelchair‑dependent, and cognitively intact, with multiple medical conditions including depression, muscle wasting, and glaucoma. This resident reported that he had been waiting at the coffee cart to pour coffee but became impatient and wheeled himself to the smoking area without getting coffee. Shortly afterward, staff walked the second resident, who had moderate cognitive impairment, dementia with agitation, and a history of combative and agitated behavior, toward the smoking area where the first resident was waiting. According to the first resident, without provocation, the second resident threw hot coffee onto his face while staff present laughed, and he did not recall any nurse offering first aid or helping him clean his face. Staff accounts and record review corroborated that the first resident returned to the nursing station with coffee on his face and clothing and reported that the second resident had spilled or thrown coffee on him. The second resident, who was holding a cup with very little coffee left, denied the act. Nursing staff acknowledged that the coffee cart was routinely left in the hallway for residents to serve themselves, that the cognitively impaired resident was forgetful, frequently ambulated in the halls, could become very agitated and paranoid, and that confused or agitated residents accessing hot coffee without supervision could result in burns to themselves or others. The facility’s own policy stated that resident supervision may need to be increased when there are temporary hazards in the environment, yet the hot beverage cart remained accessible without targeted supervision for residents with known cognitive impairment and behavioral issues, leading to the altercation involving hot coffee between the two residents.
Failure to Maintain ROM and Properly Assess Splinting and Restorative Programs
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve residents’ range of motion and mobility for five sampled residents. Resident 55, who had diagnoses including metabolic encephalopathy, COPD, and Parkinson’s disease, had an order for restorative nursing aide (RNA) active range of motion to both upper extremities three times a week, but the March 2026 RNA task schedule showed Xs on all days and the Minimum Data Set Coordinator stated the RNA treatment had not been completed until 3/19/26. The same resident’s physical therapy evaluation dated 2/3/26 identified impaired ROM in both lower extremities at both hips, knees, and ankles, but the evaluation did not include objective measurements or degrees of motion. Resident 3, who had dysphagia, dementia, and muscle wasting and atrophy, had an RNA order for a right elbow splint or rolled towel for four to six hours with skin checks every two to three hours. The Director of Rehabilitation stated the resident did not receive any OT evaluation or treatment before the RNA order for the right elbow splint, and that there should have been an OT assessment and treatment to establish safe wear time before RNA use. Resident 11, who had chronic kidney disease stage five and muscle wasting and atrophy, had RNA orders for a left elbow splint, left resting hand splint, and both knee splints, but the Director of Rehabilitation stated the resident did not receive PT or OT evaluation or treatment before those splinting orders. Resident 46, who had dysphagia, Alzheimer’s disease, and aphasia, had RNA orders for both elbow splints, both resting hand splints, and both knee splints, and the Director of Rehabilitation stated the resident never received PT or OT services before starting to wear the splints. Resident 15, who had hemiplegia affecting the right nondominant side, Parkinsonism, and traumatic brain injury, had a joint mobility assessment showing worsening right wrist flexion and extension from moderate to moderate/severe, but the facility did not adjust the resident’s program when the assessment showed the ROM had changed. The Director of Rehabilitation stated the resident should have been re-evaluated and that the facility did not make alterations to the program after the decline was identified. The facility policy stated residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM, and residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction is unavoidable.
Medication Refusal, Administration, and Resident Notification Failures
Penalty
Summary
The facility failed to ensure physician notification and required documentation when one resident repeatedly refused prescribed medications. The resident had diagnoses including schizoaffective disorder, epilepsy, and major depressive disorder, and was cognitively impaired with supervision to partial/moderate assistance needed for ADLs. Review of the MAR and nursing notes showed frequent refusals of antiseizure and antipsychotic medications over multiple months, and staff stated the facility process was to attempt the medication three times, notify the physician if refusal continued, and document the refusal and physician notification in the nursing progress notes. The record review and interviews identified no documented evidence that the physician was notified of the repeated refusals. The facility also failed to follow its medication administration and seizure-related policies for another resident with epilepsy, acute kidney failure, type 2 DM with hyperglycemia, and hypocalcemia. During medication pass observation, the resident refused Keppra, and staff acknowledged the refusal. The record review showed the resident had refused Keppra 126 times between 12/2025 and 3/19/2026, yet there was no documented seizure activity on the MAR and no documented neurologist notes in the clinical record. The physician stated the resident had been constantly refusing Keppra and requested a neurologist evaluation, but the DON stated there were no neurologist notes or physician-ordered request in the record at the time of review. The facility also failed to administer Metformin with food as ordered for the same resident. The order required Metformin 500 mg twice daily with meals, but the medication was given in the morning when the resident had not eaten breakfast. Staff and the DON acknowledged that the medication was scheduled with meals and that giving it on an empty stomach could cause adverse reactions, including hypoglycemia. In addition, during medication pass observation for a third resident with multiple psychiatric and pain-related diagnoses, an LVN administered seven medications without explaining what medications were being given or what they were for, and the LVN acknowledged the resident had the right to know what medications were being administered.
Failure to Follow Texture-Modified Menu Recipes
Penalty
Summary
The facility failed to ensure that standardized recipes and texture requirements were followed for lunch service. During tray line observation, minced and moist bread was served as large pieces of bread soaked in milk, and the cabbage was chopped while the carrots were shredded into 1-inch-long strips instead of being minced to no larger than 4 mm. During the same observation and interview, the cook stated the bread was not blended and the cabbage with carrots was prepared the same as the regular diet except for shredded carrots. The Dietary Supervisor later stated there were large pieces of bread and that the cabbage and carrots did not fit the gaps of a fork prong as required for the minced and moist diet. The facility also failed to follow the recipe for corned beef served to residents on the soft and bite size diet. During kitchen observation, the cook served minced corned beef instead of corned beef chopped into 1/2-inch pieces. The cook stated he did not follow the recipe and had blended the corned beef until it was small pieces, rather than preparing it to the prescribed size. The Dietary Supervisor stated cooks should always follow the menu and recipe to ensure the correct texture and recipe are prepared. Facility records showed the recipe for corned beef required tender meat chopped into 1/2-inch pieces, and the menu planning policy stated standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation.
Unsafe food storage, sanitation, and labeling practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. During observation, two open packages of hot dogs dated 3/10/26-3/13/26 were found stored in the walk-in refrigerator even though the Dietary Supervisor stated hot dogs should be kept for only five days after thawing. In the same refrigerator, fully cooked corned beef was stored on a lower shelf beneath raw ground beef, and a box containing 70 single-serve juice containers dated 3/5/26 was found in the walk-in refrigerator even though the manufacturer’s instructions indicated the juice should be stored frozen and used within 10 days after thawing. The Dietary Supervisor stated the juice had been stored longer than 10 days and removed it for discard. The kitchen dishwashing area also had water accumulated around the grease trap with an oil-like substance floating on the water. Storage shelves for pots were located next to the grease trap. The Dietary Supervisor stated there was significant water or backflow from the grease trap and that the area should not have standing water because it can cause bacteria growth and contamination of utensils, equipment, and food. The Maintenance Supervisor stated the water should be mopped and that standing water should not remain on the floor. A can opener blade in the food preparation area was observed to be worn, dented, stained, and covered with sticky brown residue. The Dietary Supervisor confirmed the residue and stated the blade had not been changed for a year and could not be cleaned because of the dents. In the resident refrigerator located in the ice room on the 2nd floor, the March 2026 temperature log was missing, the log had been altered to show February instead of March, and the February temperatures recorded ranged from 68-70 degrees. The DON stated refrigerated temperatures should be 41 degrees Fahrenheit or below. In the same refrigerator, there was one container of leftover food with no label or date and one container of milk dated 3/16/26 that was expired. Resident 106, who had diagnoses including paranoid schizophrenia, major depressive disorder, atrial fibrillation, anemia, anxiety disorder, and malignant neoplasm of the endometrium, was observed with five undated disposable condiment cups containing a light yellow liquid at the bedside. The resident stated the liquid was lime juice used for salads and provided by the facility kitchen. An LVN did not know what the liquid was because it was unlabeled and undated, and the Dietary Supervisor stated the lime juice should not have been left at bedside and should be discarded within two hours after every meal. The DON stated unlabeled, undated condiments at bedside place residents at risk of consuming expired food and causing food borne illness or allergic reactions.
Unsanitary Dumpster Area With Open Bins and Scattered Trash
Penalty
Summary
The facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner. During an observation of the main dumpster area behind the facility, three of four trash bins were overfilled, the lids were left open, and flies were present inside the dumpster room. Trash, including plastic cups, food containers, plastic utensils, gloves, and paper, was scattered on the ground and under the trash bins. During a concurrent observation and interview, the Maintenance Supervisor stated trash lids should stay closed so they do not bring in pests like flies and rats, and that the ground should be swept more often by housekeeping. The Dietary Supervisor stated there were plastic utensils, cups, and food containers on the ground under the trash bins and that trash should be inside the dumpster bins. The facility policy required food waste to be placed in sealed containers, trash areas to be inspected daily for debris and closed lids, and the trash collection area to be kept clean and swept and washed down regularly.
Infection Control Failures With PICC Dressing and N95 Fit Testing
Penalty
Summary
The facility failed to ensure standard infection control practices for Resident 115 by not changing the resident’s triple lumen PICC dressing within the required timeframe. Resident 115 was admitted with diagnoses including peritoneal abscess, abdominal actinomycosis, pneumonia due to Klebsiella pneumoniae, surgical aftercare following digestive system surgery, protein-calorie malnutrition, colostomy status, type 2 diabetes, and hypertension. The resident’s MDS indicated intact cognition and varying levels of assistance needed for activities of daily living. The order summary showed an order for TPN through the PICC line in the right upper arm. During a facility tour, Resident 115 was observed with a triple lumen PICC line on the right upper arm. The dressing had a labeled sticker showing a dressing change date of 3/15/2026, and beneath it was another sticker on the transparent dressing dated 3/8/2026. During interview, LVN 9 stated he did not know who placed the 3/15/2026 sticker on top of the PICC dressing. RN 1 stated PICC line changes are done every 7 days and as needed if soiled to prevent infection at the catheter site. The DON also stated PICC line dressing changes are done every 7 days and as needed if soiled, and that the dressing is changed to assess the site for signs and symptoms of infection and dislodgment. The facility also failed to ensure that three sampled staff members, CNA 2, LVN 2, and LVN 3, had N95 fit testing. During interview, the Infection Preventionist stated she could not find fit tests for those three staff members and stated fit testing is completed upon hire, yearly, and as needed. The DON stated the facility fit tests all staff annually and that fit testing is conducted to make sure the N95 mask fits properly and to prevent the spread of infection. The facility’s infection control policy stated personnel are to be trained on infection control policies and practices upon hire and periodically thereafter, and CDC guidance cited in the report stated users are required to be fit tested before using a respirator that forms a tight seal on the face.
Unassessed bedside medication storage
Penalty
Summary
The facility failed to assess whether one resident could safely self-administer medications before two prefilled 10 cc normal saline syringes were left unattended in the resident’s bedside drawer. The resident was admitted with diagnoses including peritoneal abscess, abdominal actinomycosis, pneumonia due to Klebsiella pneumoniae, surgical aftercare following digestive system surgery, protein-calorie malnutrition, colostomy status, type 2 diabetes, and HTN. The resident’s MDS dated 2/26/2026 indicated cognition was intact, but the resident required varying levels of assistance with eating, oral hygiene, dressing, personal hygiene, toileting/hygiene, showering/bathing, and footwear. During a facility tour on 3/17/2026, the two prefilled saline syringes were observed in the resident’s bedside drawer unattended. An LVN stated he did not know who placed the syringes there. An RN stated the prefilled saline flushes should not be left at bedside unattended because of improper use and contamination if a confused resident accessed or consumed the liquid. The DON stated residents are only allowed to have medications at bedside if they have been assessed as cognitively and physically able to do so and have physician approval, and that bedside medications should be kept in a locked container. The facility policy stated the interdisciplinary team and practitioner must assess each resident’s cognitive and physical abilities to determine whether self-administration is safe and clinically appropriate, and that self-administered medications must be stored in a safe and secure place not accessible by other residents.
Contract PTA with Abuse Conviction Continued Working
Penalty
Summary
The facility failed to prevent employing a contracted Physical Therapy Assistant (PTA) who had been found guilty by a court of law of abuse or mistreatment. The PTA remained on the facility’s rehab staff schedule and was working in the rehabilitation gym when surveyors observed and interviewed staff on 3/18/2026. Record review showed the PTA’s California Physical Therapy Board license had a citation issued on 2/5/2025 for a misdemeanor conviction of inflicting corporal injury, along with a citation for failure to notify the Board within 30 days of the conviction. The Director of Rehabilitation stated the rehab staff were employed by a contract rehab company and confirmed the PTA was working at the facility despite the citation. The DSD stated she saw the citation during the license renewal period, could not open the citation on the Board website, and relied on the DOR’s assurance that the PTA could continue working. The facility’s Abuse Prevention/Prohibition policy stated it does not employ anyone found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. The Therapy Services Agreement with the contract rehab company stated the company would ensure therapists met all applicable federal and state laws, rules, and regulations.
Failure to Provide Written Bed-Hold and Transfer Notification
Penalty
Summary
The facility failed to ensure that the resident or the resident’s representative were notified in writing of the transfer and bed-hold provision in accordance with the facility’s Bed-Holds and Returns policy. Resident 110 was admitted with diagnoses including PVD, HTN, and HLD, and the MDS dated 12/29/2025 indicated the resident was cognitively intact and required supervision or touching to partial/moderate assistance with ADLs. A physician order dated 1/5/2026 indicated the resident may transfer out to a general acute care hospital. A review of Resident 110’s bed hold informed consent showed the confirmation of transfer and bed-hold provision section and the 24-hour notification section were both blank. During interview and record review, the LVN stated the facility’s process is to complete bed hold consents upon admission and upon transfer to GACH, and stated the blank sections indicated the resident was not notified of the bed hold. The DON stated that a 7-day bed hold is given upon admission and discharge to the hospital, and that written notification needs to be emailed, faxed, or mailed to the resident or representative. The facility’s policy stated that prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy.
Failure to Provide SLP Services for Resident with Severe Communication Deficits
Penalty
Summary
The facility failed to provide speech and language pathology services to improve communication for a resident with significant speech and communication impairment. Resident 92 was admitted and readmitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction affecting the right dominant side, dysarthria, and anarthria. The resident’s MDS dated 3/1/2026 indicated unclear speech and that the resident usually makes self understood. The care plan, initiated on 4/2/2025 and revised on 3/13/2026, identified a communication problem related to CVA, dysarthria, and anarthria, with a goal that the resident would be able to effectively comprehend commands and interventions to evaluate comprehension and observe communication strategies. During observation on 3/16/2026, Resident 92 was sitting at the edge of the bed with a laptop, a communication book, and white paper nearby. The resident was able to answer simple yes/no questions less than half the time, stated no when asked about therapy services, and was not able to use the communication book to answer questions. The resident could lift the right shoulder slightly but could not move the right elbow or hand, while the left arm moved without restriction. Interviews with facility staff showed the resident had difficulty communicating, often pointed or staff guessed what was needed, and sometimes became frustrated and angry when staff could not understand the resident. The Director of Rehabilitation reviewed therapy records and stated Resident 92 had never received SLP services at the facility, with records going back to 2/2020. The SLP stated the resident had communication deficits and could not communicate effectively, and that the resident should have had speech therapy before the survey date and could have benefited from training to use a communication device. The SSD, MDS coordinator nurse, and DON each stated the resident would have benefited from SLP services and that the facility missed providing them. The facility policy on ADLs stated residents should receive support and assistance with communication, and the speech pathology policy described evaluation and treatment of communication disorders, including non-vocal communication device training.
Wheelchair Missing Required Hand Brake
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards for one sampled resident by providing a wheelchair that did not have two hand brakes. Resident 38 was admitted with diagnoses including muscle wasting and atrophy, osteoarthritis, and asthma. The admission fall evaluation indicated the resident was not able to perform gait and balance activities and was not able to walk straightforward or walk through a doorway and turn. The fall risk care plan, initiated shortly after admission, identified the resident as a fall risk with a goal of being free from falls and included physical therapy to evaluate and treat. During a concurrent interview and observation, Resident 38 stated she was unable to walk, needed the wheelchair, and was scared of falling because the wheelchair did not have a second hand brake. The resident was observed sitting in the wheelchair with the DOR, who stated the wheelchair needed a left side hand brake. The DOR further stated the wheelchair required two hand brakes for the resident's safety and to reduce the risk for falls when getting in and out of the chair. The DON also stated that wheelchairs provided to residents who need them require two hand brakes for safety in order to prevent an accident or injury. The facility's Falls - Clinical Protocol stated staff will document risk factors for falling and discuss the resident's fall risk.
Failure to Obtain Ordered Pain Consultation
Penalty
Summary
The facility failed to effectively manage a resident’s pain by not arranging a pain consultation that had been ordered by the physician. Resident 16 was admitted with diagnoses including low back pain, paraplegia, and stage 4 pressure ulcers of the left and right buttock. The resident’s care plan, initiated on 7/23/2025, identified a goal to minimize pain and included interventions to medicate for pain as ordered, monitor and report complaints of pain, and notify the physician if interventions were unsuccessful. A pain assessment dated 1/1/2026 documented chronic pain that affected the resident’s participation in therapy, mood, behavior, and ability to accept care. The resident’s H&P noted a bullet in the spine and that the resident had capacity to make medical decisions, and the MDS indicated the resident was cognitively intact and frequently had pain that affected sleep. Physician orders dated 3/2/2026 directed the facility to provide a stat pain management referral. The order summary listed pain-related medications including baclofen, Imitrex, lidocaine patch, Norco, and oxycodone. During interview, the resident stated he had chronic back pain rated 6/10, received pain medication about three times a day, and had been asking for a pain consult since admission without receiving one. An LVN confirmed the resident never received the pain consultation and stated the nurse who received the order should have set it up. The facility’s pain consultant physician stated he had not visited the facility since 2/10/2026, had not completed a consultation for the resident, and had not been contacted about the consult. The DON stated stat consults should be done urgently and acknowledged the resident’s pain may not have been effectively managed without the ordered pain consult.
Failure to Document Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that Resident 13, who had diagnoses including paranoid schizophrenia, schizoaffective disorder, and depression, received the necessary behavioral health care and services as outlined in the plan of care and physician orders. The resident’s care plan, developed shortly after admission, directed staff to administer psychotropic medications, discuss the ongoing need for the medications with the physician and family, and monitor, record, and document target behaviors and symptoms. The resident’s history and physical described a recent inpatient psychiatric stay for severe agitation, restlessness, impulsivity, irritability, anger episodes, intrusive behavior, and threatening behavior, and also stated the resident lacked capacity to make medical decisions. The physician’s orders required Haldol and Risperdal for specific behavioral symptoms and directed staff to monitor and document the number of episodes of mood swings, elevated mood, irritability, agitation/restlessness, depressive symptoms, auditory hallucinations, talking to self, yelling, and pacing every shift. However, the March 2026 MAR did not contain documented episodes of agitation for Haldol use or documented episodes of the listed mood and psychotic symptoms for Risperdal use during the reviewed period, including the date of the SBAR for agitation. The SBAR documented that Resident 13 charged toward nursing staff, remained agitated despite attempts to calm the resident, and required law enforcement intervention, followed by an order for Ativan and Haldol and transfer to a hospital. During observations, Resident 13 was seen walking in the hallway talking to self with staff following the resident, and later standing near the nursing station laughing, smiling, and speaking to self. RN 1 stated staff are to document target behaviors and side effects of ordered psychotropic medications and that behavior episodes are tallied monthly and evaluated by the IDT and physician every 3 months. RN 1, LVN 2, and the DON all stated that behaviors such as agitation, yelling, pacing, and anxiety should be documented on the MAR, and that failure to document targeted behaviors could affect the resident receiving the correct treatment or dosage. The facility policy also stated behavioral symptoms will be identified using facility-approved screening tools and the comprehensive assessment.
Pharmacist Failed to Identify Repeated Keppra Refusals During Monthly Drug Review
Penalty
Summary
The facility failed to ensure the consultant pharmacist performed a monthly drug regimen review that identified and reported irregularities related to a resident’s Keppra therapy. Resident 81 was admitted with diagnoses including epilepsy and acute kidney failure, and the MDS dated 1/2/2026 indicated cognition was intact and the resident was independent with most activities of daily living. The physician order summary dated 3/17/2026 included Keppra 1000 mg by mouth twice daily for seizure disorder and monitoring for seizure episodes every shift. During medication pass observation on 3/17/2026, an LVN prepared and offered Keppra 1000 mg, and Resident 81 refused the medication, stating, “I don’t need it.” Review of the MAR and physician orders with the DON showed the resident refused Keppra 126 times between 12/1/2025 and 3/19/2026, including 37 refusals in 12/2025, 39 refusals in 1/2026, 33 refusals in 2/2026, and 17 refusals from 3/1/2026 through 3/19/2026. The MAR also showed zero seizure activity across all shifts during those months and through 3/17/2026. The consultant pharmacist stated she did not regularly review the MAR, reviewed physician order recaps and nursing notes, and was not aware of how many times Resident 81 refused Keppra. She stated she did not send recommendations to the physician regarding the repeated refusals and did not see any notes from her reviews in 1/2026 or 2/2026 about irregularities in the resident’s Keppra therapy. The DON confirmed there were no pharmacist recommendations for the resident during those monthly reviews. The facility policy required the consultant pharmacist to review each resident’s medication regimen at least monthly and report findings and recommendations to the administrator, DON, attending physician, and medical director, as appropriate.
Medication Given Outside Ordered Pain Parameters
Penalty
Summary
Ensure that residents are free from significant medication errors was not met when staff failed to follow a physician’s order for pain medication for Resident 48. Resident 48 was admitted with diagnoses including anemia, hyperlipidemia, and hypotension, and the MDS dated 1/23/2026 indicated cognition was intact and that the resident required moderate assistance with toileting, hygiene, bathing, upper and lower body dressing, and personal hygiene. During a concurrent interview and record review on 3/19/2026, the DON stated that the order for Norco 5-325 mg was to give 1 tablet orally every 8 hours as needed for severe pain of 8-10/10, and that the medication had been given for light pain of 3/10, which was not within the MD order. During a phone interview, LVN 11 stated she did not remember the pain level Resident 48 reported before administering the medication on 2/8/2026 at 6:47 PM, and stated that if the resident had been at a pain level of 3, she would not have given Norco for that level of pain. The facility policy stated medications are to be administered in accordance with prescriber orders.
Improper Medication Labeling and Storage
Penalty
Summary
An open box of Assure Prism Blood Glucose Control Solution was observed in Medication Cart 4 without an open date. During the observation, the LVN reviewed the control solution package and bottles and stated the package had been opened but no open date was present. The LVN also reviewed the manufacturer labeling, which stated the control solution expires three months after opening. The DON stated the control solution must have an open date so the licensed nurse knows when it expires, and the facility policy required drug containers with missing or incomplete labels to be returned to the pharmacy before storage. Resident 12, who had diagnoses including hypertension, Type 2 diabetes mellitus, and gastro-esophageal reflux disease, had medications still stored in Medication Cart 2 after the resident had been transferred to the hospital and was no longer in the facility. During the observation, medications labeled for Resident 12 included Vitamin B-6 50 mg, Repaglinide 1 mg, and Sucralfate 1 gm. The LVN stated the resident had been gone from the facility for 7 days and that discontinued medications should not remain in the medication cart. The LVN and DON both stated that when a resident is transferred or discharged, the resident’s medications are discontinued and removed from the medication cart. The DON stated the medications should be removed from the cart and placed in the medication room to prevent medication errors. Facility policies titled Medication Holds and Storage of Medications stated held medications must be stored separately in the medication room or returned to the pharmacy, and discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
Loose Bed Grab Bar Not Maintained
Penalty
Summary
The facility failed to ensure a bed grab bar was maintained and in good working order for one resident. Resident 76 was admitted with diagnoses including dementia, type 2 diabetes mellitus, benign prostatic hyperplasia, and cognitive impairment. The resident’s MDS dated 1/27/2026 indicated severely impaired cognition, required setup or clean up with eating, oral care, and toileting hygiene, required partial moderate assistance with showering/bathing, dressing, personal hygiene, and footwear, and was ambulatory and independent with bed mobility. During a facility tour on 3/16/2026 at 10:26 a.m., Resident 76’s left bed grab bar was observed to be insecurely fastened and unstable. An LVN stated the resident had a limp and used the bed grab bars to balance and walk, and said the grab bar was loose and missing a bolt. The LVN stated he would notify the maintenance supervisor immediately. The maintenance supervisor was later observed securing and tightening the left bed grab bar. The DON stated it was the responsibility of staff during rounds to identify broken or poorly working equipment, place a sign on it, and immediately notify maintenance. Facility policies titled Hazardous Areas, Devices and Equipment and Bed Safety stated hazardous devices and equipment would be identified and addressed appropriately and that maintenance staff would inspect beds and related equipment as part of the regular bed safety program.
Insufficient Usable Living Space in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet of usable living space per resident in 30 of 38 resident rooms. A review of the Request for Room Size Waiver letter dated 4/2/2026, submitted by the Administrator, showed that 30 rooms did not meet the 80 square feet requirement per resident under federal regulation. The letter stated that the rooms’ square footage did not compromise resident privacy, adequate storage, ambulation/wheelchair access, toilet accessibility, or sufficient space for nursing care. A review of the Client Accommodations Analysis dated 3/17/2026 listed multiple rooms that fell below the required minimum, including rooms measured at 77.1, 79.4, 73.8, 73.7, 79.9, 73.5, 78.4, 79.7, 72.8, 79.6, 79.2, 79.5, 78.1, and 79.3 square feet per resident in rooms with 2, 3, or 4 beds. During observations from 3/16/2026 to 3/20/2026, residents had ample space to move freely inside the rooms, and the rooms had sufficient space for beds, side tables, and resident care equipment.
Resident Left Unassigned and Unattended on Floor in Feces Overnight
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not ensuring that staff checked on the resident every two hours for toileting and care needs during an overnight shift. The resident had diagnoses including metabolic encephalopathy, incontinence, impaired mobility, osteoarthritis, and communication deficits related to a previous stroke. An MDS dated 12/31/2025 documented that the resident had intact cognition for daily decision-making, required partial assistance for toileting, dressing, toilet transfers, and walking, and used a wheelchair for mobility. The resident also required supervision for multiple ADLs, including bathing, hygiene, transfers, and positioning. On the 11 PM to 7 AM shift, the CNA assignment sheet for that night did not list any CNA assigned to this resident. CNA1 stated that he was not assigned to the resident and that the assignment sheet did not reflect any staff responsible for the resident’s care. As a result, the resident was not checked or assisted with toileting or incontinent care for an extended period. According to interviews, at approximately 5 AM, LVN2 found the resident in her room sitting on the floor in feces and informed the RN Supervisor. CNA1 later went to assist the resident around 6:20 AM after being instructed by the RN Supervisor and found the resident still on the floor, sitting in stool with feces on her body. CNA1 and CNA3 cleaned the resident while she remained on the floor but were unable to lift her back into bed due to her weight and inability to assist with the transfer. CNA1 reported that the RN Supervisor declined to help, stating it was almost the end of his shift, and provided no assistance. CNA1 further stated that he informed the RN Supervisor that he and CNA3 were ending their shift while the resident remained on the floor. LVN2 confirmed that the resident stayed on the floor from the time she was found at approximately 5 AM until the morning shift arrived at 7 AM to assist with lifting and transferring the resident back to bed. The DON and DSD reported that they were not notified at the time of the incident, and the DON stated that no licensed nurse had informed her that the resident was found on the floor, so no root cause analysis or investigation had been conducted. Facility policies on abuse prevention and reporting defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required prompt and thorough investigation of neglect or injuries of unknown source.
Improper Low Air Loss Mattress Setting for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a low air loss (LAL) mattress was set according to the manufacturer’s weight-based guidelines for a resident with significant skin integrity risk. The resident, admitted with complete paraplegia and dependent or requiring extensive assistance for most ADLs, had an active care plan and physician order directing use of a LAL mattress for skin impairment prevention, with licensed nurses to monitor placement and functioning every shift. The manufacturer’s Dynarex LAL mattress manual specified that mattress settings should correspond to patient weight and that a low-pressure light and alarm would activate when pressure fell below the preset level. During an observation and interview, an LVN responded to the resident’s call light and found the LAL mattress alarm sounding and the low-pressure indicator flashing red. On inspection, the LVN identified that the mattress was incorrectly set at 350 lbs, while the resident’s actual weight was 106 lbs. The LVN stated the mattress should have been set to the resident’s current weight and that the treatment nurse was responsible for verifying correct settings during rounds. The DON confirmed that an incorrectly set LAL mattress can negatively impact a resident’s skin management and overall pressure injury prevention plan. The facility’s ADL policy required provision of hygiene and toileting services and interventions in accordance with assessed needs and recognized standards of practice, but the mattress setting and monitoring did not follow the manufacturer’s instructions or the resident’s care plan and orders.
Failure to Follow Fall-Risk Care Plan, CNA Assignment, and Safety Orders Resulting in Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow an identified fall-risk and incontinence care plan and physician orders for a resident with multiple risk factors, resulting in an unwitnessed fall and prolonged time on the floor. The resident was admitted with incontinence, impaired mobility, and osteoarthritis, and an MDS dated 12/31/2025 showed intact cognition but a need for partial assistance with toileting and transfers, and supervision for multiple ADLs. Care plans initiated in March 2025 identified the resident as at risk for falls related to incontinence and unawareness of safety needs, with interventions including placing floor mats for safety, keeping the bed in the lowest position, anticipating and meeting needs, promptly responding to requests for assistance, and checking the resident every two hours to assist with toileting and provide pericare after each incontinent episode. A fall risk evaluation dated 1/6/2026 identified the resident as a high fall risk requiring assistive devices and taking 1–2 medications that increased fall risk. On the night shift spanning 1/9/2026 to 1/10/2026 (11 PM–7 AM), the CNA assignment sheet contained an error in that no CNA was assigned to this resident, despite the resident’s identified needs for assistance and supervision. CNA staff later reported that when asked to provide care to the resident at approximately 6:20 AM, they reviewed the CNA assignment sheets for 1/9/2026 and 1/10/2026 and confirmed that no CNA had been assigned to the resident. LVN2, who was the charge nurse on that shift, stated that at approximately 5 AM it was the first time during that shift that she made rounds and found the resident sitting on the floor in her room. LVN2 reported that she notified the RN Supervisor and that no one responded to help her lift the resident until the 7 AM day shift arrived, noting that at least two staff were required to lift the resident due to a weight of 224 pounds. When CNA1 and another CNA went to provide care at about 6:20 AM, they found the resident on the floor sitting in feces and were unable to lift her, informing the RN Supervisor and LVN2. CNA1 reported that he and the other CNA signed out at 7 AM, leaving the resident on the floor until the oncoming shift lifted her. The facility’s Director of Nursing stated that no licensed staff informed her that the resident was found on the floor, so no root cause analysis or investigation was initiated. The Director of Staff Development stated she was not informed of the CNA assignment error and that issues affecting residents were required to be communicated immediately to leadership. A physician order summary dated 1/12/2026 directed that floor mats be placed for safety, and the care plan dated 1/12/2026 reiterated that floor mats would be placed as indicated; however, an observation on 2/3/2026 showed that the resident’s room did not have floor mats in place. Facility policies on falls and on accident/incident investigation required that a resident found on the floor be considered to have had a fall and that an investigation be initiated and documented within 24 hours, but this was not done for this event.
Failure to Provide Timely Incontinent Care and Brief Changes
Penalty
Summary
Surveyors identified that staff failed to provide incontinent care and pressure injury prevention for one resident over an approximately three-day period. The resident had complete paraplegia, intact cognition, and was dependent on staff for toileting, lower body dressing, transfers, and most ADLs, with a care plan directing that disposable briefs be changed every two hours and as needed, and that the perineal area be cleaned after each incontinence episode. On one early morning, CNA 1 provided incontinent care, applied a clean brief, and wrote his initials, time, and date on the brief because he was concerned that staff were not changing this resident as required. CNA 1 was then off duty for several days. When CNA 1 returned to work, he observed that the resident was still wearing the same incontinent brief he had applied days earlier, with the same date and time markings, indicating that the brief had not been changed during that period. Interviews with the DON and DSD confirmed their awareness that the resident had been left soiled and in the same brief for about three days, despite the resident’s history of refusal of ADLs. Facility policies on ADLs and fecal incontinence required that residents be provided hygiene and toileting services in accordance with assessed needs and that residents be cleaned after each episode of incontinence, with refusals reported to a supervisor. The failure to follow the care plan and policies resulted in the resident remaining in the same incontinent brief for days, which the DON stated placed the resident at increased risk for skin breakdown and affected his dignity.
Failure to Assess and Supervise Resident with Elopement Risk Resulting in Severe Injury
Penalty
Summary
The facility failed to ensure the safety and adequate supervision of a resident with a history of dementia, major depressive disorder, and psychosis, who exhibited exit-seeking and aggressive behaviors. Upon initial admission and subsequent readmission, the facility did not complete or properly document the required Wandering Risk and Elopement Screening Assessment. Despite multiple episodes of exit-seeking and attempts to leave the facility, the resident's care plan was not updated to reflect these behaviors, and no comprehensive elopement prevention plan was developed. On several occasions, staff observed the resident attempting to leave the facility, displaying delusional and aggressive behaviors, and expressing a desire to go home. Staff interviews revealed that the resident was known to be confused, at risk for elopement, and had previously attempted to access exits. On the day of the incident, the resident became agitated, climbed onto her bed, and began kicking a window in an attempt to escape. Although a 1:1 sitter was ordered, the assigned LVN was also responsible for 28 other residents and did not request additional staff support. The LVN did not continuously monitor the resident, and there was confusion among staff regarding who was providing direct supervision at the time of the incident. As a result of inadequate supervision and failure to intervene, the resident broke the window and sustained severe injuries, including a right tibial plateau fracture and a comminuted fracture of the fibular head and neck, requiring hospitalization and surgical intervention. Documentation and interviews further revealed that staff failed to follow up on psychiatric consult orders and did not implement immediate safety strategies as outlined in facility policies. There were also allegations of staff being pressured to falsify statements regarding the incident.
Failure to Provide Timely Behavioral Health Intervention Resulting in Resident Injury
Penalty
Summary
The facility failed to provide necessary and appropriate behavioral health care and services to a resident experiencing a mental health crisis. The resident, who had a history of major depressive disorder, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety, exhibited aggressive and erratic behavior, including attempts to elope and physical aggression. Despite these behaviors being reported by staff at the beginning of the shift, the response was limited to notifying the psychiatric nurse practitioner, who ordered a one-time dose of intramuscular Haldol and Benadryl. No order for hospital transfer was given at that time, and the resident's behavior continued to escalate. During the shift, the resident climbed onto a nightstand and broke a window with a metal object, subsequently falling and sustaining a severe injury to the right leg. Staff responded after hearing calls for help, and upon assessment, noted swelling and severe pain in the resident's right leg. Emergency services were called, and the resident was transferred to a general acute care hospital, where imaging confirmed acute, displaced fractures of the right tibia and fibula, requiring surgical intervention. The incident was witnessed by another resident, who reported feeling unsafe and disturbed by the aggressive behavior and was relieved when the resident was moved to another room. Interviews with staff revealed that the aggressive and elopement behaviors had been reported but not acted upon with sufficient urgency. The Director of Nursing acknowledged that the incident could have been avoided if the resident had been transferred for evaluation earlier, given the repeated attempts to elope and escalating aggression. The facility's policy required prompt investigation and documentation of such incidents, but the actions taken were not adequate to prevent harm to the resident and distress to others.
Failure to Maintain Safe and Comfortable Resident Environment Due to Broken Window
Penalty
Summary
The facility failed to provide a safe and comfortable environment for a resident by admitting and keeping the resident in a room with a broken window, resulting in exposure to cold temperatures for two days and nights. The broken window was not repaired in a timely manner, and the resident was not provided with extra blankets or moved to another room without a broken window. The resident reported feeling very cold and angry due to the conditions, and the room temperature was observed to be very cold during the survey. The resident involved had a history of heart failure, bipolar disorder, and acute respiratory failure with hypoxia. The resident was moderately cognitively impaired but able to ambulate independently and required varying levels of assistance with activities of daily living. Despite these vulnerabilities, the resident was left in a room with a large hole in the window, which allowed cold air to enter and created an uncomfortable and potentially unsafe environment. Facility staff, including the Maintenance Director and DON, confirmed that the window had been broken for several days and that temperature logs were incomplete or unavailable. The Maintenance Director had not ordered a replacement window until the day of the survey, and there was a lack of documentation regarding daily room temperature checks. The facility's own policy required maintenance to keep the building in good repair and free from hazards, but these procedures were not followed in this instance.
Failure to Maintain Window Screen in Good Repair
Penalty
Summary
The facility failed to maintain a window screen in good repair in one of six sampled resident rooms (Room A). During an observation, the window in Room A was found open with a large hole in the lower corner of the screen. A CNA confirmed that the window was open for ventilation and acknowledged that the hole allowed insects such as flies and mosquitoes to enter the room and reach the residents. The infection preventionist also confirmed that a hole in the window screen could allow insects to enter the resident's room. Review of the facility's policy indicated that residents are to be provided with a safe, clean, and comfortable homelike environment, including maintaining a clean and sanitary setting.
Call Light Not Kept Within Reach for Resident
Penalty
Summary
The facility failed to ensure that the call light was kept within reach for one of three randomly selected residents. Resident 3, who was cognitively intact and required partial to moderate assistance with activities of daily living, was observed and interviewed after she had been calling out for help for approximately four hours without response. The call light, which is the primary method for residents to request assistance, was found on the floor and out of her reach. Resident 3 reported that this was a common occurrence and that she was unable to get help when needed, specifically mentioning discomfort due to bunched-up clothing that she could not adjust herself. Staff interviews confirmed that the call light was not accessible to the resident, and both the Registered Nurse Supervisor and the Director of Nursing acknowledged that call lights must be within reach to allow residents to request assistance for their needs. A review of the facility's policy and procedures also indicated that staff are required to ensure call lights are accessible to residents at all times. The failure to keep the call light within reach was directly observed and confirmed by staff, and was not in accordance with the facility's established procedures.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
Facility staff failed to promote dignity and respect for a resident by not providing clean clothing, linens, and timely incontinence care. The resident, who had diagnoses including End Stage Renal Disease, dependence on hemodialysis, and chronic obstructive pulmonary disease, required moderate to maximal assistance with most activities of daily living. During observation, the resident was found in the hallway with unzipped pants and a stained t-shirt, and reported feeling embarrassed and uncared for due to lack of staff assistance in maintaining a presentable appearance, especially when attending dialysis appointments. The resident also stated that incontinence briefs were often left soiled for extended periods, leading to periods without any incontinence protection. Further observation revealed the resident's clothing strewn on the floor and a bed with a large yellow stain on the sheets. A Licensed Vocational Nurse confirmed the resident's unkempt appearance and acknowledged that the resident's rights and dignity were not being honored. The Director of Nursing also stated the importance of cleanliness for hygiene and dignity. Facility policies reviewed indicated that residents should be provided with a clean, comfortable, and homelike environment, and be treated with respect and dignity, which was not upheld in this instance.
Failure to Develop Care Plan for Resident with Memory Problems
Penalty
Summary
The facility failed to develop a care plan for a resident with a history of memory problems. This deficiency was identified during a review of the resident's admission record, which indicated diagnoses including paranoid schizophrenia, anemia, diabetes mellitus, major depressive disorder, and hypertensive heart disease. The Minimum Data Set (MDS) assessment revealed that the resident's cognitive skills for daily decisions were severely impaired, and the resident required assistance for activities of daily living, such as toilet transfers and walking, although they were independent with bed mobility. Despite the resident's history of memory problems and noncompliance noted in the Baseline Care Plan, no comprehensive care plan was developed to address these issues. An interview with an LVN confirmed that a care plan should have been created if memory problems were present upon admission. The facility's policy and procedures require a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's needs, but this was not implemented for the resident in question.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the attending physician conducted face-to-face visits with a resident as required by regulations. Specifically, for one resident, the attending physician did not make the necessary visits after a certain date, despite the resident having complex medical conditions and cognitive impairments. The resident was admitted with diagnoses including paranoid schizophrenia, anemia, diabetes mellitus, major depressive disorder, and hypertensive heart disease. The Minimum Data Set indicated that the resident had severely impaired cognitive skills and required assistance with activities of daily living. During interviews and record reviews, it was confirmed that there were no physician progress notes in the resident's medical record after a specific date, indicating a lapse in required visits. The facility's policy stated that the attending physician must visit residents at least once every thirty days for the first ninety days following admission, and then at least every sixty days thereafter. However, the physician did not adhere to this schedule, as verified by the Medical Records Director, who confirmed the absence of physician notes after the specified date.
Failure to Arrange Timely Transportation for Resident's Medical Appointment
Penalty
Summary
The facility failed to honor a resident's right to be seen by a physician by not arranging reliable transportation, resulting in the resident missing a scheduled medical appointment. The resident, who was cognitively intact and independent in activities of daily living, had informed the facility staff about the appointment two weeks in advance. Despite confirmation from the staff that transportation was arranged, the transport arrived late, causing the appointment to be canceled. The Director of Social Services (DSS) acknowledged that the resident had notified the facility about the appointment and that transportation was arranged through the resident's insurance for a 10 am pickup. However, on the day of the appointment, the DSS discovered that the transportation had been canceled and had to arrange for an alternative, which arrived too late. The DSS admitted that the issue could have been avoided if the facility staff had confirmed the transportation arrangements one or two days before the appointment. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, and supporting them in exercising their rights, which was not upheld in this instance.
Inadequate Living Space for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate living space for Resident 4, who was cognitively impaired and dependent on assistance for all activities of daily living. Resident 4 was placed in a semiprivate room that did not meet the required minimum of 80 square feet per resident in multiple resident bedrooms. During an observation, it was noted that Resident 4's space was encroached upon by Resident 2's belongings, reducing Resident 4's livable space to 48.44 square feet. This situation was confirmed by the Maintenance Director, who acknowledged the deficiency in space allocation. Resident 2, who shared the room with Resident 4, was cognitively intact and required only setup or clean-up and supervision for activities of daily living. The room measured 164.47 square feet in total, which should have provided each resident with 82.24 square feet of space. However, due to the clutter from Resident 2's belongings, Resident 4's space was compromised. The Facility Administrator confirmed the clutter and acknowledged the potential impact on privacy, dignity, and safety. The facility's policy on providing a homelike environment was not adhered to, as the environment was not orderly or adequately accommodating for Resident 4.
Failure to Address Ceiling Leak Poses Fall Risk
Penalty
Summary
The facility failed to maintain a safe environment for residents by not addressing a persistent water leak in the ceiling of a room occupied by two residents. Resident 2, who was cognitively intact and independent in activities of daily living, and Resident 3, who had moderate cognitive impairment and required assistance for daily activities, were both at risk due to the water leak. The leak, which had been ongoing for two days, resulted in water dripping onto Resident 3's bed and accumulating on the floor, creating a potential fall hazard. Interviews with staff revealed that the ceiling had been repaired multiple times without success, and the water leak persisted whenever it rained. Despite the known risk, the residents were not moved to another room, and only temporary measures such as placing buckets to catch the water were implemented. Staff acknowledged the safety hazard posed by the wet floor, which could lead to falls and injuries. The facility's policy emphasized the importance of maintaining an environment free from accident hazards, yet the issue remained unresolved, putting the residents at risk.
Facility Fails to Address Ceiling Leaks and Thermostat Malfunction
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents, staff, and the public by not addressing water leaks in the ceiling of a room occupied by two residents. Resident 2, who is cognitively intact and independent in activities of daily living, and Resident 3, who has moderately impaired decision-making skills and requires assistance with daily activities, were affected by the leaking ceiling. The ceiling above Resident 3's bed was observed to be leaking, with water dripping onto the bed and accumulating on the floor, creating a potential safety hazard. Despite the issue being reported, the residents were not moved to another room, and the problem persisted due to unsuccessful repair attempts. Additionally, the facility did not ensure that all thermostats were in safe operating condition. One of the thermostats was reported to be malfunctioning, affecting the temperature control in multiple rooms, including the Director of Nursing's office. The Maintenance Director acknowledged the issue, indicating possible electrical or mechanical failure, which could compromise residents' health and comfort. The facility's policy requires the maintenance department to keep the building and equipment in safe and operable condition, which was not adhered to in this instance.
Elevator Malfunction Poses Risk in Facility
Penalty
Summary
The facility failed to ensure that the elevator was in safe working condition, which had the potential to cause harm to residents, staff, and visitors. During an observation, a Monitor Aide (MA) reported that the elevator frequently stopped functioning, requiring him to reset the breaker in the parking garage to restore its operation. This malfunction occurred 3-4 times during his shift, and the issue was known to the Maintenance Supervisor, Administrator, and Nursing Supervisors. A Certified Nursing Assistant (CNA) and the Director of Nursing (DON) confirmed awareness of the problem, with the CNA having been stuck in the elevator previously. The DON was in discussions with the corporate office regarding repairs. The Maintenance Assistant (MA) revealed that the elevator had been malfunctioning for at least a year, with multiple employees getting stuck daily. An urgent inspection by the elevator company had been conducted, and an invoice for repairs was provided to the Administrator. However, the elevator had not been repaired as of the report date. A review of the facility's maintenance policy indicated that the maintenance department is responsible for keeping equipment safe and operable at all times, which was not adhered to in this case.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that three residents had their Advance Directives or Advance Directives Acknowledgement forms documented in their active medical records. This deficiency was identified during interviews and record reviews, which revealed that the residents were not fully informed of their right to formulate advance directives. This oversight had the potential to conflict with the residents' healthcare wishes and deny them the right to request or refuse medical care and treatment. Resident 97 was admitted with diagnoses including diabetes mellitus, hypertension, and chronic kidney disease. Despite having intact cognition and requiring partial to moderate assistance with activities of daily living, there was no advance directive noted in the resident's medical record. The Registered Nurse Supervisor confirmed the absence of the document and emphasized its importance in understanding the resident's end-of-life wishes. The Director of Nursing also stated that advance directives or declinations should be immediately accessible in residents' charts to prevent unnecessary or unwanted medical treatment. Resident 48, who was admitted with conditions such as hemiplegia, muscle wasting, and morbid obesity, had intact cognition for daily decision-making but did not have a signed advance directive in the chart. Similarly, Resident 105, with diagnoses including metabolic encephalopathy and major depressive disorder, had moderately impaired cognition and no advance directive in the clinical record. The Licensed Vocational Nurse confirmed the absence of these documents and the lack of evidence that the residents' representatives were informed about advance directives. The facility's policy required that advance directives be completed within 72 hours of admission, but this was not adhered to in these cases.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to properly store and dispose of controlled and non-controlled medications according to its policy and procedures. During an observation and interview, it was revealed that expired medications were being destroyed by two-night shift licensed nurses, contrary to the facility's policy which required the Director of Nursing (DON) to handle the destruction of narcotics. Additionally, the storage container for narcotics in the DON's office was not locked or permanently affixed, making it easily accessible and posing a risk for medication diversion. The DON described the process for narcotics disposition, which involved counting by two licensed nurses before removal from medication carts, followed by storage in the DON's office until a pharmacist could waste the medication. However, the facility lacked a log or record of the dates, times, and contact information for the pharmacist or the company responsible for picking up the controlled medications. The facility's policy required that all destruction logs be maintained at the facility for at least three years, but this was not being followed, leading to a lack of accountability for these medications.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices, as observed during a survey. A cell phone and personal speaker were found on the preparation sink, which is an area designated for food preparation. The individual responsible for these items acknowledged that personal items should not be in the kitchen area due to infection control concerns. Additionally, opened bags of hashbrowns in the kitchen's chest freezer were not labeled with an open date, and the Dietary Services Supervisor confirmed that the date the hashbrowns were opened was unknown. This lack of labeling could lead to the use of expired foods. Furthermore, a Dietary Aide was observed loading dirty pots and pans into the dish machine and then handling clean and sanitized dishes without washing hands between these actions. The Dietary Aide admitted to not washing hands and recognized the importance of doing so to prevent cross-contamination. The Director of Nursing emphasized the necessity of labeling food with open dates to ensure residents do not receive expired foods. The facility's policy on sanitization and refrigerated storage procedures were reviewed, indicating the need for maintaining cleanliness and proper labeling of food items.
Deficiency in Laundry Equipment Maintenance
Penalty
Summary
The facility failed to ensure that all essential equipment was in working order, specifically an industrial washing machine used for washing facility linen. During observations, it was noted that one of the two industrial washing machines in the laundry room was not operational, displaying an error message. Interviews with the Assistant Maintenance Supervisor (AMS) and Assistant Laundry Supervisor (ALS) revealed that the machine had been out of service for about a month due to a missing part that needed to be ordered and installed. The AMS was not familiar with the installation process, and no technician had been scheduled to perform the repair. The Director of Nursing (DON) was unaware of the status of the part order or repair appointment, acknowledging that the lack of a second machine could delay the delivery of clean linen to residents. This deficiency had the potential to significantly delay the provision of clean and sanitary linen for all 111 medically compromised residents, potentially causing frustration among residents due to delays in having their linen changed. The facility's policy required maintenance to ensure all equipment was operable, but this was not adhered to in this instance.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from two residents, Resident 50 and Resident 84, before initiating treatment with psychotropic medications. Resident 50, who was diagnosed with schizophrenia, major depressive disorder, gout, chronic kidney disease, and type II diabetes, had a history and physical indicating the capacity to make decisions. However, the Minimum Data Set (MDS) showed moderate cognitive impairment. Consent for medications such as Mirtazapine and Divalproex Sodium was obtained without the resident's signature, and the nurse's verification signature was unidentifiable. The physician's signature was also missing for Mirtazapine. Similarly, Resident 84, diagnosed with osteoarthritis, chronic kidney disease, major depressive disorder, anxiety disorder, hypertensive heart disease, and diabetes mellitus, had intact cognition according to the MDS. Consent for medications like Sertraline and Trazadone was obtained without the resident's signature, and the nurse's verification was missing. The facility's policy requires informed consent to be signed by the resident or their representative and verified by a healthcare professional, which was not adhered to in these cases.
Failure to Provide Homelike Environment Due to Lack of Bed Linen
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for one resident, resulting in the resident feeling uncomfortably cold while resting in bed without adequate bed coverings. The resident, who was cognitively intact and required supervision and assistance with activities of daily living, was observed without a top sheet, blanket, or pillowcase. The deficiency was noted during an observation in the resident's room, where it was found that the resident had only a fitted sheet on the bed. The issue arose when a CNA removed the resident's linen in the morning to change it but did not replace it due to a lack of clean linen available on the floor. The CNA confirmed that residents should always have a top sheet, blanket, and pillowcases, but was unable to provide these due to the unavailability of linen. The Director of Nursing acknowledged that all residents have the right to a homelike environment, which includes having a fully made bed with clean linen daily. The facility's policy on providing a homelike environment emphasizes the importance of clean bed and bath linens.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident, identified as Resident 96, who required extensive help due to conditions such as cerebral palsy and muscle wasting. Despite having intact cognitive skills, Resident 96 needed significant assistance with tasks like bathing, showering, toileting, and mobility. The resident reported not being changed in a timely manner by the 3-11 shift nurses, leading to prolonged periods in soiled conditions. The resident also mentioned that the Hoyer lift was reportedly broken, preventing regular showers, although later observations confirmed that the lifts were in working condition. Interviews and record reviews revealed that there was no ADL charting for Resident 96 for the month of November, which was confirmed by the Medical Record Director and the Director of Nursing. The lack of documentation and failure to provide necessary ADL care resulted in the resident feeling angry and embarrassed, with the potential for skin infections and irritation. The facility's policy indicated that residents unable to perform ADLs independently should receive necessary services to maintain hygiene and grooming, which was not adhered to in this case.
Failure in Colostomy Care Leads to Skin Excoriation
Penalty
Summary
The facility failed to provide appropriate colostomy care for Resident 114, resulting in excoriation and potential risk for infection at the colostomy site. Resident 114, who was admitted with a diagnosis of colostomy malfunction, was observed to have a reddened and macerated colostomy site. The resident reported that the colostomy bag was not being changed as needed, sometimes going an entire day without a change, which contributed to the skin irritation. The Licensed Vocational Nurse (LVN) confirmed the resident's account and acknowledged that neglecting timely colostomy bag changes could lead to redness, infection, and skin breakdown. The Treatment Nurse (TN) corroborated that the colostomy was supposed to be changed daily and as needed, emphasizing that failure to do so could result in skin breakdown, pain, and infection. The facility's policy on Colostomy/Ileostomy Care, revised in 2010, was intended to prevent exposure of the resident's skin to fecal matter, yet the policy was not adhered to in this case. The Minimum Data Set (MDS) indicated that Resident 114 was cognitively intact and required assistance with Activities of Daily Living (ADLs), highlighting the need for staff to provide the necessary care and attention to prevent such deficiencies.
Failure to Complete Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-hemodialysis assessment for a resident, identified as Resident 88, who required dialysis services due to end-stage renal disease (ESRD) and diabetes. The resident was admitted to the facility with a diagnosis of ESRD and was dependent on hemodialysis, which was scheduled for Tuesdays, Thursdays, and Saturdays. The physician's orders required the facility staff to monitor the resident's left AV shunt for bruit and thrill daily and to remove the AV fistula shunt dressing four to six hours after dialysis treatment. The facility's dialysis care plan included monitoring vital signs and reporting any signs of infection at the access site. However, the facility's dialysis communication forms lacked post-dialysis assessments on multiple occasions, specifically on 8/12/2024, 9/17/2024, 10/1/2024, 11/12/2024, 12/17/2024, and 12/30/2024. The Registered Nurse Supervisor (RNS 2) confirmed that the post-dialysis assessments were not completed as required, and there were no progress notes documenting these assessments in the resident's electronic health record. The Director of Nursing (DON) acknowledged that the dialysis communication form was intended to monitor the resident's vital signs before and after dialysis, and failing to assess the resident upon return from dialysis could result in the facility not addressing changes in the resident's health condition. The facility's policy on Hemodialysis Access Care required documentation of the catheter location, dressing condition, dialysis occurrence, and post-dialysis observations, which were not adhered to in this case.
Failure to Retrieve Resident's Personal Belongings
Penalty
Summary
The facility failed to ensure that the social service designee followed up with the sending facility regarding a resident's personal belongings. This deficiency involved a resident who was originally admitted with multiple diagnoses, including hemiplegia and hemiparesis following a cerebral infarction, muscle wasting and atrophy, hyperlipidemia, hypertension, and morbid obesity. The resident was capable of making her needs known but could not make medical decisions. Despite having intact cognition for daily decision-making, the resident expressed frustration over the lack of assistance in retrieving her personal belongings from the previous skilled nursing facility. During an interview, the social service designee admitted to contacting the previous facility but was unable to provide specific details or documentation regarding the transfer of the resident's belongings. The facility's policy on social services, which includes assisting residents in maintaining their highest practicable well-being and coordinating resources to meet their needs, was not adequately followed. This oversight had the potential for the resident's personal property to be misplaced or lost.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility staff failed to adhere to infection control measures in two specific instances. During a facility tour, a clean bedside table, clean linen, and a wheelchair were found stored in the bathroom of a resident's room. A Certified Nursing Assistant (CNA2) was unable to identify who placed these items there and acknowledged that they should not be in the bathroom due to infection control concerns. The Director of Nursing (DON) confirmed that such items should not be stored in bathrooms as they can become contaminated, posing an infection control risk to residents. In another instance, a Licensed Vocational Nurse (LVN 5) was observed exiting a resident's room while wearing gloves and holding a topical medication cream in the hallway. LVN 5 admitted that this practice was against infection control protocols, as personal protective equipment (PPE) should be doffed and disposed of before leaving a resident's room. Additionally, LVN 5 was unaware of which resident in the room was under enhanced barrier precautions, despite a sign indicating such precautions at the room's entrance. These actions had the potential to cause cross-contamination and spread infections within the facility.
Facility Fails to Maintain Safe Environment for Resident
Penalty
Summary
The facility failed to maintain a safe and operable environment for Resident 68, as evidenced by the presence of a broken trim on the wall near the resident's bed, missing knobs on the closet door, and an exposed wire running from the television to the window. These issues were present when Resident 68 was admitted to the room, and the resident expressed frustration over the lack of repairs. The Maintenance Assistant confirmed the presence of these hazards and noted that the Maintenance Supervisor had recently resigned without leaving a repair list or instructions, leaving the assistant unaware of necessary repairs throughout the facility. Resident 68 was admitted with diagnoses including cerebral infarction and hyperlipidemia and was oriented to person, place, and time. The Minimum Data Set indicated that the resident had mild cognitive impairment and required extensive assistance with daily activities. The facility's policy and procedures for maintenance services, revised in 2009, state that the maintenance department is responsible for keeping the building in good repair and free from hazards, a standard that was not met in this instance.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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