Monterey Healthcare & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Rosemead, California.
- Location
- 1267 San Gabriel Blvd, Rosemead, California 91770
- CMS Provider Number
- 555897
- Inspections on file
- 41
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Monterey Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
The facility failed to follow its Water Management Plan by allowing a broken mercury temp gauge on one water heater, keeping another water heater at 110 F instead of the required 145 F, and finding sink water temps at Nursing Station A below 110 F and at Nursing Station B above 110 F. The MS also stated he visually checked drained water for crystal-like structures, but there was no log documenting those visual checks for biofilm, rust, sediment, or contamination.
The facility failed to implement and update person-centered care plans for three residents with significant clinical and psychosocial needs. A resident with hemolytic anemia had a care plan directing staff to monitor and document specific anemia symptoms, yet staff and the ADON acknowledged that only routine labs were obtained and there was no documented monitoring for the listed signs and symptoms, even after a hospitalization for critically low HGB/HCT. Another resident with schizophrenia and depression developed new verbal threats toward staff, repeatedly saying "I want to hit you," but an LVN did not complete a change in condition form, did not notify the physician, and did not update the care plan, despite facility protocol for such behaviors; later, this resident threw coffee toward another resident during an activity and was transferred for psychiatric evaluation. A third resident with schizophrenia, lack of coordination, and documented impaired vision reported difficulty seeing, inability to participate fully in activities, and feeling unheard, while activity staff and the AD noted poor participation and low self-esteem related to vision problems; the DON confirmed there was no care plan addressing this resident’s visual impairment, contrary to facility policy on comprehensive person-centered care planning.
Dishwasher thermometer not reading accurately. The facility’s low-temp dishwasher was observed running below the required wash and rinse temperatures on three consecutive cycles, with readings remaining under 120 F each time. The DS stated the machine’s thermometer was not reading accurately, and the Dietitian stated that dishes would not be cleaned if the dishwasher did not reach the goal temperatures.
A resident with schizophrenia, depression, and auditory hallucinations, whose care plan required monitoring and reporting of any risk of harm to others, began making new verbal threats such as “I want to hit you” toward staff about a month after admission. An LVN observed this behavior but did not document it, did not complete a Change in Condition form, did not update the care plan, and did not notify the physician, despite facility policy requiring physician notification for significant mental or psychosocial changes. Later, after the resident threw coffee toward another resident during an activity, a Change in Condition form was completed and the NP ordered transfer to a hospital, but the earlier unreported verbal threats formed the basis of the deficiency.
A resident with schizophrenia, bipolar disorder, anxiety, depression, and documented delusions had a care plan identifying risk for verbal and physical aggression, but over a period of weeks developed increased verbal aggression, delusional accusations that others were stealing her medications, and episodes of withdrawal. Nursing notes, CoC documentation, and the MAR recorded multiple episodes of cursing, yelling, and aggression toward staff and other residents, with staff sometimes unable to redirect her. Although the ADON contacted the psychiatrist about possible medication changes, the psychiatrist did not complete an in‑person evaluation during this period, and the ADON did not escalate concerns to the NP or psychiatric medical director despite recognizing that existing interventions were ineffective and the resident could harm others. Ultimately, the resident approached another resident who was quietly reading, used a racial slur, and elbowed her in the face, demonstrating the facility’s failure to implement adequate interventions and supervision to prevent accidents and resident‑to‑resident aggression.
A CNA was observed feeding a resident while standing over her instead of sitting at eye level during mealtime. The resident had schizophrenia, anxiety disorder, adult failure to thrive, and severe cognitive impairment, and the CNA later stated she should have been seated with the resident. The LVN and DON stated staff should be seated with residents during feeding, and the facility’s feeding procedure and resident rights policy required staff to assist residents in a comfortable seated position and treat them with dignity.
A resident with schizophrenia, depression, and cannabis use was admitted without receiving written AD information upon admission. The SSD later provided the AD pamphlet several days after admission, and both the SSD and DON acknowledged the facility was not following its policy requiring written information about the resident’s right to accept or refuse treatment and formulate an AD.
A resident with paranoid schizophrenia, schizophrenia, and DM with diabetic CKD was readmitted after hospitalization and later had increased hallucinations and delusions, prompting a physician order for transfer to a GACH for psych evaluation. The care plan was not revised to reflect the change in condition or transfer, and the DON confirmed there was no updated care plan to guide the resident’s plan of care.
A nurse administered medications to two residents without telling them the name or purpose of each medication. One resident had schizophrenia, depression, and anxiety, with orders for psychotropic, cardiac, seizure, and vitamin supplements; the other had schizoaffective disorder, bipolar disorder, and major depressive disorder, with orders for mood stabilizers, bowel management, neuropathic pain, antipsychotic, and EPS medications. In both observed med passes, the nurse verified identity and gave the meds but did not explain them, and the DON stated residents have the right to know what medications they are receiving.
Failure to monitor a resident with hemolytic anemia and follow up on hematology care. The resident’s care plan called for monitoring and documenting anemia symptoms such as pallor, fatigue, dizziness, syncope, headache, palpitations, weakness, SOB on activity, sore tongue, chest pain, tinnitus, and changes in condition, but staff did not adequately assess and monitor the resident or follow up with the Hematology Clinic after the visit. The resident later had critically low RBC, HGB, and HCT, abnormal BP, was sent to the GACH via 911, and received 4 units of PRBC.
Incorrect Clozaril Label on Medication Cart: A resident with bipolar disorder, schizophrenia, and other mental health diagnoses had an active order for Clozaril 37.5 mg PO daily, but the bubble pack on the med cart was labeled 37.5 mg BID. An LVN confirmed the label did not match the active order and stated the old bubble pack had not been properly removed or replaced, leaving the medication stored with inaccurate dose and frequency information.
A resident with DM, metabolic encephalopathy, and schizophrenia had MAR entries showing pioglitazone was administered even when BS was below the ordered hold parameter of 120 mg/dL. An LVN stated one documented administration was actually a charting error and confirmed awareness of the hold order, while facility policy required accurate records and medication administration according to physician orders.
Excessive Resident Occupancy in Multiple Rooms: The facility failed to keep four resident rooms within the required occupancy limit, with rooms identified as 12-bed, 7-bed, and 6-bed rooms housing more than four residents each. The ADM stated the facility had a waiver and wanted an additional waiver, while records confirmed the over-occupied rooms. Residents and CNA reported adequate space, and surveyors observed room for mobility devices and care activities, but the rooms still exceeded the standard limit.
Insufficient Resident Room Space: The facility failed to provide the required square footage per resident in 12 of 22 rooms, including multiple 2-bed, 3-bed, 4-bed, 7-bed, and 12-bed rooms. The ADM stated a room waiver was in place, and residents and staff reported no concerns with room size; surveyors observed residents moving freely with enough space for beds, lockers, and mobility devices.
A resident with severe cognitive impairment, gait abnormalities, and paranoid schizophrenia walked into an open door during the night shift, sustaining a bleeding cut above the right eye. A CNA witnessed the incident and brought the resident to the nurses’ station, where an RN and an LVN assessed the wound and provided first aid but did not initiate a change-in-condition evaluation or notify the MD, and did not document the accident in the record. The injury was later identified on the morning shift when staff observed the resident’s eyebrow laceration and eyelid discoloration, completed a change-in-condition form, and contacted the MD, who ordered transfer to a hospital. This sequence of events occurred despite a facility policy requiring licensed nurses to notify the MD and a family representative after any incident or accident resulting in injury with potential need for physician intervention.
A facility failed to verify a resident's admission orders by not reviewing complete discharge documents from a GACH. The nurse relied on a clinical summary and previous records, communicating orders to the physician via SMS without verbal confirmation. The DON stated that protocol required discussing discharge summaries with the physician, which was not followed, risking incorrect medication administration.
A facility failed to provide appropriate training for its staff to care for a resident with PTSD, resulting in inadequate care. The resident, with multiple mental health diagnoses, did not receive trauma-informed care due to the absence of specific in-services on PTSD. Interviews with CNAs and the DSD revealed a lack of awareness and training on PTSD, despite facility policies indicating the need for such education.
The facility did not post daily nurse staffing information in a location accessible to both residents and visitors, as required by their policy. The ADON and DSD acknowledged the oversight, with the DSD admitting to posting the information only on a window accessible to visitors. The Administrator confirmed that residents have the right to access this information.
The facility failed to ensure proper sanitation and food handling practices by not securing all hair within a hairnet during meal preparation. A Dietary Aide was observed with exposed hair while assisting in meal preparation for 69 residents, posing a risk of contamination. Interviews with staff confirmed awareness of the risks, and the facility's policy requires effective hair restraints in kitchen areas.
The facility failed to implement a proper Water Management Program to prevent Legionella growth, as the IP was unaware of national standards and risk assessments. The facility only tested for Legionella with 10 or more pneumonia cases, and there was no evidence of water heater flushing for February. The policy referenced ASRAE guidelines, but there was no evidence of their implementation.
The facility failed to ensure the lint screens in laundry machines were cleaned as scheduled, as evidenced by incomplete documentation in the Lint Cleaning Log. This oversight was confirmed by the Laundry Services and Infection Preventionist, who acknowledged the absence of documented evidence for the cleaning of lint screens, posing a potential fire hazard.
A resident with intact cognition and independence in daily activities was observed wearing loose jeans held up by an elastic glove, leading to exposure of private areas. Despite staff awareness, no measures were taken to provide properly fitting clothing, compromising the resident's dignity.
A resident with cognitive impairments was allowed to sign informed consent for psychotropic medications without a surrogate decision-maker or interdisciplinary team meeting, despite documented evidence of their inability to make medical decisions. The facility failed to verify the resident's mental status before obtaining consent, violating their rights and potentially exposing them to inappropriate care.
A resident's safety was compromised when the call light in a shower room was positioned too high, making it unreachable. The facility's policy required call lights to be within reach, but this was not followed, as confirmed by a CNA and Maintenance Staff. The resident, with intact cognition and requiring assistance, expressed concerns about safety due to the inaccessible call light.
Two residents experienced privacy violations in a facility due to peeling stained-glass window films in common restroom and shower areas, allowing visibility from the patio. Despite awareness of the issue, staff were unsure of how long the films had been in disrepair, compromising residents' privacy rights.
The facility failed to create comprehensive care plans for two residents. One resident was discharged without a detailed discharge plan, and another resident with PTSD did not have a specific care plan addressing PTSD management. The facility's policy required comprehensive care plans, but this was not followed, leading to potential confusion and inadequate care.
A resident with PTSD, schizoaffective disorder, and other mental health conditions experienced re-traumatization and increased hallucinations due to the facility's failure to provide trauma-informed and culturally competent care. The facility did not adequately assess or document the resident's trauma history or triggers, and staff were unaware of the resident's PTSD diagnosis. This led to the resident experiencing distress and behavioral issues, resulting in multiple hospitalizations.
A facility failed to provide necessary behavioral health care for a resident with PTSD, schizoaffective disorder, and other mental health issues. The resident exhibited agitation and made homophobic comments, but the facility did not document or address PTSD triggers. Family and staff interviews revealed a lack of inquiry into the resident's trauma history, and care plans did not adequately involve family or address PTSD. Observations showed the resident's distress, and staff acknowledged the importance of identifying triggers to prevent re-traumatization.
A resident received Bactrim for nearly a year without a stop date, contrary to the facility's Antibiotic Stewardship policy. The prolonged use, identified during a review, exceeded the recommended 14-day course, posing a risk of antibiotic resistance. The Infection Preventionist Nurse was unaware of the extended administration due to the lack of a documented end date.
The facility was found to have four rooms exceeding the regulatory limit of four residents per room, with two rooms housing twelve residents each, one with seven, and another with six. Despite this, residents reported no concerns, and observations indicated adequate space and care. The facility had a waiver and planned to request another, asserting no impact on care quality.
The facility did not meet the required minimum of 80 square feet per resident in twelve rooms, affecting various bed capacities. Despite the deficiency, residents reported no concerns about space, and no adverse effects were observed during the survey. The Administrator acknowledged the issue and mentioned a room waiver in place.
A resident with a history of falls and severely impaired cognition fell and suffered an acute subdural hematoma after attempting to stand without supervision on the facility's patio. Despite documented needs for supervision, staff were not in close proximity, violating the facility's safety policy.
Two residents at high risk for elopement left the facility unsupervised due to inadequate monitoring and supervision. One resident, with fluctuating decision-making capacity and suicidal ideation, climbed the roof and escaped during a shift change. A week later, another resident with no decision-making capacity and similar diagnoses eloped from the same location. The facility lacked dedicated staff to monitor the patio during the night shift, and the patio doors were left unlocked, contributing to these incidents.
A facility failed to create a care plan for a resident with a history of drug abuse who was allowed to go out on pass. Despite the resident's medical history, including schizophrenia and drug abuse, the facility did not document specific interventions to monitor the resident's behavior. The DON acknowledged the lack of a care plan and stated that interventions were communicated verbally, without a written policy.
A resident with a history of suicidal ideations and fluctuating decision-making capacity eloped from an ambulance en route to a hospital. The LTC facility failed to promptly investigate or locate the resident after being informed that the resident was not admitted to the hospital. The facility's ADM and AC did not follow up with the hospital or ambulance company, and the incident was not reported to law enforcement. The facility lacked a policy for ensuring safe resident transfers.
A resident with psychosis, major depressive disorder, and dementia eloped from the facility due to inadequate monitoring and supervision. The resident was found the next day at a nearby school football field. The facility lacked scheduled monitoring for the breezeway area and continuous surveillance camera monitoring during the day and evening shifts.
Failure to Maintain Water Heater Temperatures and Monitoring Logs
Penalty
Summary
The facility failed to implement its infection prevention and control program by not maintaining the water system in accordance with its Water Management Plan for the Prevention of Waterborne Pathogens. During observation and interview, Water Heater 1 behind the laundry room was found with a broken mercury temperature gauge, and the Maintenance Supervisor stated he did not know how long it had been broken. Water Heater 2 behind the kitchen was also observed, and the Maintenance Supervisor stated its mercury temperature gauge should be at 110 F. The facility’s Water Management Plan, reviewed with the Infectious Preventionist Nurse, stated the water heater temperature should be 145 F. The Maintenance Supervisor checked sink temperatures at Nursing Station A and Nursing Station B and found Nursing Station A ranged from 86 F to 105 F, which he stated was too low, and Nursing Station B ranged from 116 F to 120 F, which he stated was too high. He stated the water temperature at sinks should be 110 F. He also stated he performed visual checks of the water heaters by draining them and inspecting the initial drained water for crystal-like structures, but there was no log documenting the visual monitoring of the drained water appearance for biofilm, rust, sediment, or contamination.
Failure to Implement and Update Person-Centered Care Plans for Anemia, Behavioral Changes, and Vision Impairment
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans for three residents with identified needs. For one resident with acquired hemolytic anemia, the care plan initiated at readmission included detailed interventions to educate the resident and caregivers about expected stool changes and to monitor, document, and report specific signs and symptoms of anemia such as pallor, fatigue, dizziness, syncope, headache, palpitations, weakness, feelings of cold, low HGB/HCT, shortness of breath on activity, sore tongue, chest pain, tinnitus, and changes in condition. The resident’s MDS showed intact cognition and active diagnoses including anemia, heart failure, HTN, and renal insufficiency. A change of condition evaluation documented abnormal vital signs and a critical lab result that led to transfer to a GACH, and the care plan was later revised to note very low HGB and HCT values. However, there was no evidence that new or updated interventions were added after the hospitalization and readmission, and interviews with the ADON and nursing staff confirmed that, although routine labs were ordered every three months, there was no documented monitoring for the physical signs and symptoms of anemia as specified in the care plan. For a second resident with schizophrenia, depression, and auditory hallucinations, the MDS indicated moderately impaired cognition and a need for supervision or touch assistance with most cares, and it documented that the resident did not exhibit verbal behavioral symptoms directed toward others at that time. The existing care plan addressed a mood disorder with interventions to monitor and report risks of harming others, such as increased anger, labile mood, agitation, feeling threatened, or thoughts of harming someone. Progress notes from a provider visit indicated no suicidal or homicidal ideations and no violent behavior. According to an LVN, about a month after admission the resident began expressing frustration by saying "I want to hit you" to staff, which was described as a new behavior. The LVN acknowledged there was no documentation of these verbal threats in progress notes, no change in condition form was completed, and the care plan was not updated to reflect the new threatening behavior or to prompt physician notification, despite facility protocol that residents expressing intent to harm themselves or others should be placed on one-to-one supervision and have a CIC completed. A later CIC documented that during a coffee social activity the resident stood up, spoke loudly, and threw a cup of coffee toward another resident, leading to notification of the NP and transfer to a GACH on a 5150 hold. For a third resident admitted with schizophrenia, lack of coordination, depression, and anxiety, the MDS documented intact cognition and impaired vision, with the ability to see large print but not regular print. Observations during a karaoke activity showed the resident sitting close to the TV, holding a microphone, looking down, not singing, and stating to activity staff that he wanted to hear the song but could not sing along because he could not read the words on the TV; he was also observed squinting at the TV and at staff. In interviews, the resident reported being partially blind, having difficulty seeing, wanting to participate in more activities but being unable to due to impaired vision, and feeling that staff did not listen to his concerns. Activity staff reported that the resident often complained about not being able to see well, did not participate in some activities because of poor vision, and would not attend group activities that could not accommodate his visual impairment. The activities director stated that one-to-one activity visits were needed because the resident was not actively participating in group activities and presented with low self-esteem, expressing that he felt like a burden. During a record review, the DON confirmed there was no care plan addressing the resident’s poor vision, despite the facility’s policy requiring development and implementation of a comprehensive person-centered care plan to support residents in attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.
Dishwasher thermometer not reading accurately
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in its kitchen used by 66 residents because the dishwasher machine thermometer was not functioning properly. During observation with the Dietary Supervisor, the low-temperature dishwasher was run three times, and the wash and rinse temperatures remained below the stated minimum goal of 120 degrees Fahrenheit on each run, with readings of 100/102 F, 110/112 F, and 110/112 F. The Dietary Supervisor stated that the dishwasher temperatures should have reached at least 120 F to properly clean the dishware. During interview, the Dietary Supervisor stated that if the dishwasher did not reach the goal temperatures, staff would need to use the three-compartment sinks to handwash dishes while the machine was out of order. The Dietitian stated that if the dishwasher did not reach the goal temperatures of 120 F to 150 F, the dishes would not be cleaned and pathogens from dirty dishes could transfer to residents. On the following day, the Dietary Supervisor stated that a repair person assessed the machine and found that the dishwasher thermometer was not reading accurately, and she did not know how long it had not been working. The facility policy stated that the dish machine would be routinely monitored during use to ensure appropriate temperatures.
Failure to Notify Physician of Resident’s New Verbal Threats and Behavioral Change
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a resident’s new behavior of making verbal threats toward staff, as required by the resident’s care plan and the facility’s change in condition policy. The resident was admitted with schizophrenia, depression, and auditory hallucinations, and had a care plan initiated in January that directed staff to monitor, record, and report to the physician any risk of the resident harming others, including increased anger, labile mood, agitation, or thoughts of harming someone. The resident’s MDS from late January indicated moderately impaired cognition and no verbal behavioral symptoms directed toward others. However, according to an LVN, beginning about one month after admission, the resident began verbalizing “I want to hit you” to staff when he did not get what he wanted. The LVN acknowledged that this was a new threatening behavior that started in February, but there was no documentation of these verbal threats in the progress notes, no Change in Condition (CIC) form was completed, and the care plan was not updated to reflect this new behavior. The DON stated she was not aware that the resident was making verbal threats and confirmed that facility protocol required staff to create a CIC, update the care plan, and notify the physician when a resident expressed verbal threats such as “I want to hit you.” The facility’s written Change in Condition policy required the licensed nurse to notify the resident’s physician and legal representative when there is an incident involving the resident or a significant change in the resident’s mental or psychosocial status. On a later date, a CIC was completed after the resident threw coffee toward another resident during an activity, and the NP was notified and ordered transfer to a general acute care hospital for evaluation. Prior to this incident, however, the new pattern of verbal threats toward staff was not reported to the physician or documented as a change in condition, constituting the cited failure to immediately notify the physician of a significant change in the resident’s behavior.
Failure to Manage Escalating Aggression and Delusions Resulting in Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions and supervision for a resident with escalating verbal aggression and delusions, which resulted in that resident physically striking another resident. Resident 54 was admitted with schizophrenia, anxiety disorder, bipolar disorder, depression, psychotic disorder, and documented delusions, and had a conservatorship order stating she was gravely disabled and unable to provide for basic personal needs. Her care plan, initiated on 2/13/2026, identified potential for verbal and physical aggression related to ineffective coping skills, mental and emotional illness, and poor impulse control, with goals that she not harm herself or others. Interventions listed included analyzing triggers and circumstances, assessing coping skills and support systems, anticipating and assessing needs, and identifying and addressing contributing sensory deficits. In the days leading up to the incident, multiple records documented a clear increase in Resident 54’s verbal aggression and delusional thinking. A Change of Condition (CoC) evaluation on 3/9/2026 at 5:30 PM recorded that she was verbally aggressive, cursing, yelling, and shouting at staff and other residents, with staff attempting redirection and close monitoring for safety. Nursing progress notes from 3/9/2026 through 3/12/2026 described multiple episodes of increased verbal aggression toward staff and residents, with staff sometimes able to redirect her and sometimes unable to do so. The Medication Administration Record for March 2026 documented 13–16 episodes of increased delusions and aggression toward staff and residents between 3/9/2026 and 3/15/2026. Staff interviews confirmed that for approximately one to three weeks before the physical incident, Resident 54 had increased verbal aggression, increased delusions, and periods of withdrawal and staying in bed, and that she sometimes did not comply with redirection. Despite these documented changes, the facility did not implement additional or modified interventions beyond redirection and monitoring, nor did it effectively escalate concerns for timely psychiatric evaluation. The Assistant Director of Nursing (ADON) spoke with the psychiatrist (Physician 5) on 3/10/2026 about possible medication adjustments, and the psychiatrist stated he would conduct an in‑person evaluation before making changes, but he did not come to the facility between 3/10/2026 and 3/13/2026. A nursing note on 3/13/2026 documented that the ADON attempted to call the psychiatrist and was unable to reach him, and the ADON acknowledged he did not notify the psychiatrist’s nurse practitioner or the psychiatric medical director, even though existing interventions were not effective and the resident had the potential to harm others. On 3/16/2026 at 7:00 AM, a CoC record documented that a CNA witnessed Resident 54 elbow Resident 25 in the right cheek while Resident 25 was quietly reading her Bible in her wheelchair in an alcove. Statements from staff and residents indicated that Resident 54 approached Resident 25, used a racial slur, and then struck her with an elbow to the right side of the face. The facility’s Resident Safety policy required evaluation when there is a change of condition to identify circumstances that pose a risk for safety and well‑being, but the documented escalation in aggression and delusions was not met with effective interventions to prevent the physical assault.
Feeding Assistance Provided While Standing Over Resident
Penalty
Summary
The facility failed to ensure that staff assisted a resident with dining in a manner that promoted dignity when a CNA was observed feeding the resident while standing rather than sitting at eye level. The resident had diagnoses including schizophrenia, anxiety disorder, and adult failure to thrive, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS dated 3/17/2026 indicated severe cognitive impairment and active diagnoses of schizophrenia, anxiety disorder, and depression. The resident’s diet order included a regular standard portion diet with level 6 soft and bite-sized texture and thin liquids. During observation in the dining room, the resident was seated at a dining table while the CNA stood over the resident and spoon-fed the resident twice. Another staff member whispered into the CNA’s ear, after which the CNA stopped spoon-feeding and instead prompted the resident to eat items on the meal tray, but remained standing the entire time while staying with the resident until the meal was finished. The CNA stated she should have been sitting down with the resident and not standing over her. The LVN and DON both stated staff should be seated with residents at eye level during feeding and should not stand over them, and the facility’s feeding procedure and resident rights policy both stated staff should assist residents in a comfortable seated position and treat residents with kindness, respect, and dignity.
Failure to Provide Advance Directive Information on Admission
Penalty
Summary
The facility failed to ensure that one of three sampled residents, Resident 75, was provided written information regarding Advance Directive rights upon admission. Resident 75 was admitted on [DATE] with diagnoses including schizophrenia, depression, and cannabis use. The resident's H&P dated 3/22/2026 indicated the resident did not have the capacity to understand and make decisions. During interview and record review, the Social Services Director stated the Advance Directive pamphlet was provided on 3/26/2026, six days after admission, and acknowledged it should have been given upon admission on 3/20/2026. Facility staff also stated the facility was not following its Advance Directive policy, which required written information to be provided upon admission. The DON stated the pamphlet should have been provided when the resident was admitted so the resident would be aware of their rights and medical wishes could be followed.
Failure to Revise Care Plan After Psychiatric Change in Condition
Penalty
Summary
The facility failed to revise or update the care plan for Resident 72 after the resident was readmitted following hospitalization and experienced increased hallucinations and delusions. Resident 72’s record showed diagnoses including paranoid schizophrenia, schizophrenia, and diabetes mellitus with diabetic chronic kidney disease. The resident’s H&P dated 3/25/2026 indicated the resident did not have the capacity to understand and make decisions. A physician order dated 3/16/2026 directed transfer to a GACH for psych evaluation with a 7-day bed hold. A change in condition evaluation dated 3/11/2026 documented complaints of lower back pain after the resident alleged a fall from a 50-foot elevator, but the resident was able to ambulate and move the lower extremities without difficulty, denied numbness, and denied head injury. The same evaluation noted increased hallucinations and delusions with a recommendation from the physician for transfer to the hospital for psych evaluation. Review of the care plans showed no revision for the transfer to the hospital on 3/11/2026, and the DON confirmed during interview that there was no care plan for the transfer and that a revised care plan should have been in place to follow the resident’s plan of care.
Failure to Explain Medications During Administration
Penalty
Summary
The facility failed to ensure that two residents were informed of the name and purpose of each medication at the time of administration. During medication passes, LVN 4 was observed preparing and handing medications to both residents after verifying their names and dates of birth, but without explaining what the medications were or why they were being given. In both observations, the nurse checked the residents’ mouths after administration to confirm the medications were swallowed. Resident 9 had diagnoses including schizophrenia, depression, and anxiety disorder. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated cognition was intact and that the resident was receiving antipsychotic, antianxiety, and antidepressant medications. The resident also had physician orders for benztropine mesylate, Depakote, Keppra, vitamin B12, Lasix, metoprolol tartrate, folic acid, multivitamin-minerals, and potassium chloride. On the observed medication pass, the resident received the morning medications without any explanation from LVN 4 about the medications or their purposes. Resident 16 had diagnoses including schizoaffective disorder, bipolar disorder, and major depressive disorder. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated moderate cognitive impairment and antipsychotic medication use. The resident had physician orders for divalproex sodium, polyethylene glycol 3350 powder, gabapentin, multivitamin-minerals, loxapine succinate, and Artane. During the observed medication pass, LVN 4 again administered the medications without telling the resident what each medication was or why it was being given. LVN 4 stated she normally informs residents of each medication and why they are receiving it, but forgot that morning. The DON stated staff should inform residents of their medications and roughly explain what each medication was, and also stated residents have the right to know what medications they are receiving.
Failure to Monitor Resident With Hemolytic Anemia and Follow Up on Hematology Care
Penalty
Summary
Provide appropriate treatment and care according to orders, resident preferences, and goals was deficient for a resident with acquired hemolytic anemia, hypertension, and schizophrenia. The resident’s care plan, initiated on 11/17/2025, directed staff to educate the resident and caregivers about stool color changes and to monitor and document/report signs and symptoms of anemia, including pallor, fatigue, dizziness, syncope, headache, palpitations, weakness, feeling cold, low HGB and HCT, shortness of breath on activity, sore tongue, chest pain, tinnitus, and changes in condition. On 2/18/2026, the resident’s lab results showed critically low RBC, HGB, and HCT values, and a change-of-condition evaluation documented abnormal BP of 94/43, HR 99, RR 16, and temperature 98.8 F, with a critical lab result and blood pressure prompting the PCP to recommend transfer to the GACH via 911. The report states the facility failed to assess and monitor the resident for signs and symptoms of hemolytic anemia and failed to follow up with the Hematology Clinic regarding the after-visit care plan. The resident was transferred to the GACH, where additional labs showed even lower RBC, HGB, and HCT values, and the resident received a total of four units of packed RBC during the hospitalization from 2/18/2026 to 2/23/2026.
Incorrect Clozaril Label on Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals stored in Medication Cart A were labeled in accordance with accepted professional principles for one sampled resident. Resident 46 was admitted with diagnoses including bipolar disorder, schizophrenia, and bipolar type schizoaffective disorder, and the record also showed a conservatorship finding that the resident was gravely disabled due to a mental health disorder. The resident’s MDS indicated intact cognitive skills, hallucinations, and active diagnoses that included anxiety disorder, depression, bipolar disorder, psychotic disorder, and schizophrenia. A review of the resident’s active order summary showed Clozaril (clozapine) 37.5 mg by mouth once daily for schizophrenia. During concurrent review of the medication cart and interview with an LVN, the current Clozaril bubble pack label was observed to state 37.5 mg twice daily, which did not match the active order’s dose and frequency. The LVN stated the active order and the bubble pack label were not the same and did not know why the old bubble pack had not been properly disposed of and replaced with a new one with the correct medication, dose, and frequency. The facility policy stated that prescription labels must include the resident’s name, route, medication name, strength, and specific directions for use, and that improperly or inaccurately labeled medications are rejected and returned to the dispensing pharmacy.
Inaccurate MAR Documentation for Diabetes Medication
Penalty
Summary
The facility failed to accurately document the administration of pioglitazone for one sampled resident with diagnoses including metabolic encephalopathy, schizophrenia, and DM. The resident’s order required pioglitazone 45 mg by mouth daily for DM, with the medication to be held if blood sugar was less than 120 mg/dL. Review of the February and March 2026 MAR showed entries indicating the medication was administered on multiple dates when the resident’s blood sugar was documented below the ordered parameter, including 89 mg/dL, 110 mg/dL, 77 mg/dL, 84 mg/dL, and 114 mg/dL. During interview, an LVN stated the MAR check mark on 3/10/2026 indicated administration, but said there was no way the medication was actually given and that the entry was a charting error. The LVN confirmed awareness of the order to hold pioglitazone if blood sugar was less than 120 and stated the documented blood sugar value for that date was accurate. The facility’s policy required medical records to be complete and correct, and its medication administration policy required medications to be administered according to physician orders and federal and state regulations.
Excessive Resident Occupancy in Multiple Rooms
Penalty
Summary
The facility failed to ensure that four resident rooms accommodated no more than four residents each. During the survey, rooms 1, 5, 20, and 26 were identified as having more than four residents per room, including two 12-bed rooms, one 7-bed room, and one 6-bed room. The Administrator stated during the entrance conference that the facility had a waiver in place for the rooms and wanted to request an additional waiver that year. A review of the facility’s Client Accommodations Analysis form and request for an additional room waiver confirmed that the rooms exceeded the standard room occupancy limits. The waiver request stated that the rooms provided adequate space for nursing care and wheelchair access and that the multiple beds did not adversely affect resident health and safety. During the survey, residents in the affected rooms were observed to have enough space to move freely, with beds and lockers in place and room for wheelchairs, walkers, and canes. Resident 4 stated the room size was okay and that wheelchairs and other equipment were used by other residents without restrictions. CNA 5 stated residents did not complain about room size or having multiple roommates. The resident census review showed that the residents occupying rooms 1, 5, 20, and 26 during this survey were not the same residents who occupied those rooms during the prior recertification survey.
Insufficient Resident Room Space
Penalty
Summary
The facility failed to provide a minimum of 80 square feet per resident in 12 of 22 resident rooms, including rooms 1, 2, 3, 4, 6, 9, 21, 26, 27, 28, 30, and 31. The affected rooms included one 12-bed room, one 7-bed room, two 4-bed rooms, two 3-bed rooms, and six 2-bed rooms. The facility's Client Accommodations Analysis and room waiver request documented that several of these rooms measured less than the required square footage per resident, with examples including a 12-bed room at 79.1 square feet per resident, 2-bed rooms at 63, 66.5, 70, and 75 square feet per resident, 4-bed rooms at 67 and 72 square feet per resident, 7-bed room at 79.8 square feet per resident, and 3-bed rooms at 78 square feet per resident. During the survey, the Administrator stated that multiple rooms did not have the required space per resident but that a room waiver was in place and an additional waiver would be requested. Residents and staff interviewed stated they had no concerns with the room size, and observations showed residents in the affected rooms had enough space to move freely, with beds and lockers present and room for wheelchairs, walkers, and canes. The survey also noted that there were no observed adverse effects related to the adequacy of space, nursing care, comfort, or privacy, and that the residents occupying the affected rooms during this survey were not the same residents who occupied those rooms during the prior recertification survey.
Failure to Notify MD After Resident Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician at the time of an accident that resulted in a head injury. The resident had paranoid schizophrenia, lack of coordination, and gait and mobility abnormalities, and an MDS dated 1/29/26 documented severe cognitive impairment and a need for supervision with most activities of daily living. On 3/7/26 around 3 AM, a CNA observed the resident turn a corner in the hallway and bump his face into the edge of an open door that protruded into the hallway, resulting in a cut above the right eye with bleeding. The CNA brought the resident to the nurses’ station, where an LVN and an RN assessed the cut and provided first aid. Despite the observed accident and visible injury, the LVN and RN on the night shift did not initiate a Change in Condition Evaluation (CIC) form and did not notify the resident’s physician of the incident. There was no documentation in the resident’s progress notes or CIC records related to the 3 AM accident. As a result, the day shift staff initially considered the injury to be of unknown origin because they were unaware of how the resident sustained the right eye injury. The facility’s later investigation confirmed that the injury occurred when the resident walked into the door during the night shift. Later that morning, at 8:45 AM, a CIC was completed when the resident was seen in the shower room rubbing his right eyebrow, with bleeding noted and a 1.2 cm cut on the right eyebrow and discoloration of the right upper eyelid. The CIC documented that the skin change and a neurological assessment were relevant to the change in condition, and the physician was notified at 9 AM and recommended transfer to a general acute care hospital for medical clearance. The facility’s policy titled “Change in Condition” required licensed nurses to notify the physician and the resident’s representative when there is an incident or accident involving the resident, or an accident resulting in injury with potential need for physician intervention. The failure of the night-shift licensed nurses to initiate a CIC and notify the physician at the time of the accident constituted the cited deficiency.
Failure to Verify Admission Orders
Penalty
Summary
The facility failed to ensure that licensed staff verified a resident's admission orders by reviewing the resident's medical history and discharge orders from a general acute care hospital (GACH) upon readmission. The resident, who had diagnoses including schizophrenia and bipolar disorder, was readmitted to the facility with specific medication orders from the hospital. However, the nurse responsible for the admission did not review the complete discharge documents and only relied on a clinical summary report and previous medication records to input the resident's readmission orders. The nurse communicated the orders to the physician via SMS, assuming agreement if the message was read, without verbal confirmation. The Director of Nursing (DON) indicated that the facility's protocol required licensed nurses to discuss discharge summaries with the admitting physician to confirm medication orders. The facility's policy also stated that the attending physician should provide medication orders upon admission. The failure to follow these procedures resulted in a potential risk of the resident not receiving the correct medications and care needed for their diagnosis.
Lack of PTSD Training for Staff
Penalty
Summary
The facility failed to ensure that its nursing staff had the appropriate competencies to care for a resident diagnosed with PTSD, as identified through resident assessments. Resident 11, who was admitted and readmitted with multiple mental health diagnoses including PTSD, did not receive care from staff trained in trauma-informed care. The facility's Director of Staff Development (DSD) admitted that there were no in-services related to trauma or PTSD provided to the staff, and the topic was not brought up to the Administrator or Director of Nursing. Interviews with Certified Nurse Assistants (CNAs) revealed a lack of awareness and training regarding trauma or PTSD. CNA 2, CNA 3, and CNA 4 all stated they had not received specific training on how to care for residents with PTSD, and they were not aware of any residents diagnosed with PTSD in the facility. This lack of training and awareness among the staff resulted in Resident 11 not receiving the appropriate care needed for their condition. The facility's policy and procedures on Trauma-Informed Care indicated that staff should be educated on the specific needs of residents who have experienced trauma, including PTSD. However, the facility's failure to implement these policies and provide necessary training led to a deficiency in care for Resident 11, as the staff did not have the competencies required to manage the resident's PTSD and related behaviors effectively.
Failure to Post Nurse Staffing Information Accessibly
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent location that was readily accessible to both residents and visitors, as required by their policy and procedure titled 'Nursing Department - Staffing, Scheduling & Postings.' During an observation and interview with the Assistant Director of Nurses (ADON), it was noted that there was no visible daily nurse staffing information posted. The ADON acknowledged that the postings should be accessible and visible for residents and visitors. The Director of Staff Development (DSD) admitted to posting the nurse staffing information on the visiting window, which was only accessible to visitors and not to residents. The DSD was unaware that residents should have access to this information. The Administrator confirmed that it was a resident's right to be informed about nurse staffing, and the postings should be accessible in the residents' area. The facility's policy, revised in 2018, indicated that nurse staffing postings must be in a prominent place readily accessible to residents and visitors.
Improper Hair Restraint in Food Preparation
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, specifically in ensuring that all hair was properly secured within a hairnet during meal preparation. During a dining observation, a Dietary Aide (DA 1) was seen with hair exposed outside of the hairnet while assisting in the preparation of meal trays for all 69 residents in the facility. This observation was confirmed during an interview with DA 1, who acknowledged the importance of securing all hair to prevent contamination and the associated risks of infection or illness. Further interviews revealed that the kitchen staff, including the cook, were aware of the risks associated with exposed hair in food preparation areas. The Assistant Director of Nursing (ADON) also emphasized the requirement for anyone entering the kitchen to wear a hairnet and ensure no hair is exposed. A review of the facility's policy and procedures, revised in 2024, confirmed the requirement for effective hair restraints in kitchen and food storage areas, highlighting a lapse in adherence to these standards.
Inadequate Legionella Management in Water System
Penalty
Summary
The facility failed to implement proper infection control practices by not ensuring its Water Management Program adhered to national, state, and local measures to prevent and monitor the growth of Legionella. During an interview, the Infection Preventionist (IP) revealed that the facility only tested for Legionella if there were 10 or more pneumonia cases, citing cost concerns. The facility had five water heaters, which were reportedly flushed monthly, but there was no documented evidence of flushing for February 2025. The IP was unaware of the meaning of terms like 'good' or 'bad' in the Water Heater Legionella Management Plan and did not know if the plan was based on a national standard. The facility's Water Management Plan, revised in February 2024, lacked specific measures for Legionella management, and the IP was unfamiliar with the risk assessment process outlined in the facility's policy and procedure. The policy indicated the need for a risk assessment to determine Legionella growth risk and the use of national guidelines to develop control measures. However, the IP was unaware of these requirements. The facility's policy also referenced the American Association of Heating Refrigeration and Air-Conditioning Engineers (ASRAE) guidelines for Legionella prevention, which included quarterly water quality measurements and maintenance of chemical levels, but there was no evidence these measures were implemented. The State Operational Manual required a documented water management program based on national standards, but the facility failed to demonstrate compliance with these requirements.
Failure to Document Lint Screen Cleaning in Laundry Machines
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for all 69 residents, staff, and the public by not ensuring that the lint screens in the laundry machines were cleaned as per the established schedule. The Lint Cleaning Log for the dates 2/12/2025 and 2/13/2025 was incomplete, lacking documentation that the lint screens were cleaned for two out of three dryer machines on 2/12/2025 and for all three machines on 2/13/2025. This oversight was confirmed during interviews with the Laundry Services (LS) and the Infection Preventionist (IP), who both acknowledged the absence of documented evidence for the cleaning of lint screens. The facility's policy, titled 'Laundry - Safety' and revised on 1/1/2012, mandates that all machines and appliances be checked daily to ensure they are clean and free of defects. However, the failure to document the cleaning of lint screens as per the schedule posed a potential fire hazard, as acknowledged by both the LS and the IP. The LS emphasized the importance of regular lint screen cleaning to prevent fires, while the IP noted the uncertainty of whether the last scheduled person on 2/12/2025 had completed the task due to the lack of documentation.
Resident Dignity Compromised by Ill-Fitting Clothing
Penalty
Summary
The facility failed to promote respect and dignity for a resident who was observed wearing jeans that were too loose and held up with an elastic glove tied to the belt loops. This resulted in the resident's jeans frequently falling down, exposing his buttocks and groin area in front of other residents, staff, and visitors. The resident expressed a desire for properly fitting pants, indicating awareness and discomfort with the situation. The resident, who has diagnoses of paranoid schizophrenia and hyperlipidemia, was noted to have intact cognition and was independent in various activities of daily living. Despite this, the staff, including a CNA, acknowledged the issue with the resident's clothing but did not take appropriate measures to ensure the resident's dignity was maintained. The facility's policy emphasizes the importance of providing care that promotes dignity and respect, which was not adhered to in this instance.
Failure to Verify Resident's Capacity for Informed Consent
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 56, was fully informed and understood their health status, care, and treatments. Despite the resident's documented lack of mental capacity to make medical decisions, as indicated in multiple assessments including the Health & Physical assessment, psychiatric notes, and a neuropsychological evaluation, the facility allowed the resident to sign informed consent for psychotropic medications without the involvement of a surrogate decision-maker or an interdisciplinary team meeting. This oversight occurred even though the resident's medical records consistently highlighted cognitive impairments such as loose associations, distractibility, and hallucinations. The Social Service Director acknowledged that the mental status assessment was not verified by the physician before obtaining informed consent, which placed the resident at risk of making uninformed medical decisions. The facility's policy required a clear determination of the resident's capacity and the identification of a decision-maker, which was not adhered to in this case. The failure to conduct an interdisciplinary team meeting or arrange for a surrogate decision-maker when the resident lacked capacity violated the resident's rights and potentially exposed them to inappropriate medical care.
Inaccessible Call Light in Shower Room
Penalty
Summary
The facility failed to accommodate the needs of a resident by not ensuring that the call light was within reach in the shower room. This deficiency was identified during an observation and interview with a Certified Nursing Assistant (CNA) who was unable to reach the call light switch lever, which was positioned too high on the wall. The Maintenance Staff confirmed that a string or cord should have been attached to the call light switch lever to make it accessible for residents. The facility's policy required that call alert devices be placed within the resident's reach, but this was not adhered to in the shower room. The resident involved, who had been admitted with diagnoses including schizophrenia and hypertension, had intact cognition and required assistance with various activities of daily living. During an interview, the resident expressed that having the call light within reach would make them feel safer in the shower room. The Assistant Director of Nursing (ADON) acknowledged that all call lights should be accessible to ensure residents' needs and safety, especially during emergencies. The facility's failure to comply with its policy and procedure on the communication-call system resulted in a deficiency that could potentially impact resident safety.
Privacy Violation Due to Peeling Window Films
Penalty
Summary
The facility failed to ensure the privacy of two residents, identified as Resident 41 and Resident 119, when using common restroom and shower facilities. The deficiency was observed in the [NAME] Wing's shower room and the East Wing's restroom, where the stained-glass window films were peeling off, allowing visibility from the front patio. This issue was noted during observations on February 11, 2025, and confirmed through interviews with staff, including a Certified Nursing Assistant (CNA) and the Maintenance personnel, who acknowledged the problem but were unsure of how long the films had been in disrepair. Resident 41, admitted with schizoaffective disorder and hyperlipidemia, was found to have intact cognition and required assistance with personal care tasks. During an interview, Resident 41 expressed concern about privacy, stating she would not shower if she knew others could see through the window. Similarly, Resident 119, who had schizophrenia and hypertension, also had intact cognition and required assistance with personal care. He expressed discomfort with the possibility of being seen while using the restroom. The facility's policy on resident rights, which includes privacy and confidentiality, was not adhered to, as confirmed by the Assistant Director of Nursing (ADON) and the Housekeeper (HSKP). The HSKP mentioned that addressing the peeling window films was an ongoing project since a previous survey identified the issue. Despite this, the problem persisted, compromising the residents' right to privacy as guaranteed by state and federal laws.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 68, who was admitted with schizophrenia and depression. Although the resident was discharged to a transition care facility, the staff did not create a detailed care plan addressing discharge planning. The Assistant Director of Nursing (ADON) acknowledged that the Social Services Director (SSD) was responsible for initiating the discharge care plan, which was not done. This oversight could lead to confusion in the resident's care and discharge process, as the interdisciplinary team did not have a structured plan to follow. For Resident 11, the facility did not develop a specific care plan to address the management and triggers of Post-Traumatic Stress Syndrome (PTSD). Resident 11, who had a history of childhood trauma and PTSD, was admitted with multiple mental health diagnoses, including schizophrenia, schizoaffective disorder, and bipolar disorder. The care plan included interventions for behavioral problems but did not specifically address PTSD. The ADON stated that a separate care plan for PTSD was expected to guide staff in managing the resident's care and identifying potential triggers. The facility's policy on Comprehensive Person-Centered Care Planning required that all goals and interventions from the baseline care plan be included in the comprehensive care plan. However, the facility did not adhere to this policy for both residents. The lack of specific care plans for discharge planning and PTSD management indicates a failure to provide resident-specific care, which is essential for maintaining continuity of care and communication among staff.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to a resident diagnosed with PTSD, schizoaffective disorder, schizophrenia, and bipolar disorder. The resident experienced re-traumatization and increased hallucinations and delusions, leading to multiple hospitalizations. The facility did not adequately assess or document the resident's trauma history or triggers, despite the resident's history of childhood trauma and PTSD being known to family members. The resident's care plans and assessments lacked documentation of trauma triggers, and staff members were unaware of the resident's PTSD diagnosis and potential triggers. Interviews with staff revealed a lack of awareness and training regarding trauma-informed care, with staff unable to identify residents with PTSD or their specific needs. The facility's policy on trauma-informed care was not effectively implemented, as staff did not assess the resident's trauma history or engage with family members to understand the resident's triggers. Observations and interviews indicated that the resident exhibited aggressive and homophobic behavior, which was not adequately addressed by the facility. The facility's failure to provide appropriate care and interventions for the resident's PTSD and trauma history resulted in the resident experiencing distress and behavioral issues. The facility's policies on trauma-informed care were not followed, leading to a deficiency in providing culturally competent and trauma-informed care to the resident.
Failure to Address PTSD Triggers in Resident
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with multiple mental health disorders, including PTSD, schizoaffective disorder, schizophrenia, and bipolar disorder. The resident, who had a history of recent trauma, exhibited behaviors such as agitation, yelling, and attempts to hit staff members. Despite these behaviors, there was no documented evidence of the resident's triggers, which are crucial for managing PTSD and preventing re-traumatization. The resident's care plans, initiated upon readmission, included interventions such as anticipating needs, assisting in developing coping skills, and monitoring behavior episodes. However, these plans did not adequately address the resident's PTSD triggers or involve the family in understanding the resident's history of trauma. Interviews with family members and staff revealed that the facility did not inquire about the resident's PTSD history or address the deep trauma and homophobia that the resident experienced. Observations of the resident's behavior included arguing, talking to himself, and making homophobic comments towards staff members. Interviews with facility staff, including the ADON and the Administrator, highlighted the importance of identifying PTSD triggers to prevent re-traumatization and potential harm. The facility's policy on behavior management indicated that assessments should be conducted to address mood or behavior problems, but the implementation of these assessments and interventions was insufficient for this resident.
Prolonged Antibiotic Use Without Reassessment
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of Bactrim, an antibiotic. The resident, who was admitted with diagnoses including heart failure, asthma, schizophrenia, and depression, was prescribed Bactrim for HIV without a specified stop date. This oversight led to the resident receiving the antibiotic for nearly a year, far exceeding the recommended 14-day course. The Infection Preventionist Nurse was unaware of the prolonged administration due to the lack of a documented end date. The facility's policy on Antibiotic Stewardship, which aims to optimize antibiotic use and reduce resistance, was not adhered to in this case. The prolonged use of Bactrim without reassessment or a stop date posed a risk of developing antibiotic resistance. The deficiency was identified during a review of the resident's records and an interview with the Infection Preventionist Nurse, who acknowledged the oversight and the potential for adverse health outcomes due to the extended use of the antibiotic.
Facility Exceeds Resident Room Capacity Limits
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to a maximum of four. During the survey, it was observed that four rooms in the facility exceeded this limit, with two rooms accommodating twelve residents each, one room with seven residents, and another with six residents. The facility's administrator acknowledged the situation and mentioned that a waiver was in place, with plans to request an additional waiver. Despite the non-compliance, the administrator claimed that the number of residents per room did not impact the care provided. Interviews with residents in the affected rooms revealed that they did not have concerns about the number of residents sharing their space. Observations during the survey indicated that the rooms provided adequate space for movement and the use of mobility aids, such as wheelchairs and walkers. The survey did not find any adverse effects on the residents' care, comfort, or privacy due to the room arrangements. The facility's request for a waiver highlighted that the room sizes allowed for adequate nursing care and accessibility, and the survey confirmed that the care and services provided were not compromised.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in twelve out of twenty-two resident rooms. These rooms included a variety of bed capacities, ranging from two to twelve beds per room. The Administrator acknowledged the deficiency, stating that the facility had a room waiver in place and intended to request an additional waiver. Despite the deficiency, the Administrator claimed that the room size did not impact the care provided to residents. Observations and interviews with residents in the affected rooms revealed that they did not express concerns about the space available to them. Residents were able to move freely with assistive devices such as wheelchairs and walkers. The facility's Client Accommodations Analysis confirmed that the rooms did not meet the required square footage per resident. However, during the survey, no adverse effects related to the inadequate room size were observed, and residents were seen to have enough space to move freely and receive care without restrictions.
Failure to Supervise High-Risk Resident Leads to Fall
Penalty
Summary
The facility failed to implement its policy and procedure on resident safety by not providing adequate supervision to a resident at high risk for falls. This resulted in the resident suffering an acute subdural hematoma after falling while attempting to stand up from a sitting position on the facility's patio without staff supervision. The incident occurred when a staff member observed the resident sitting on the patio's brick seating area and later saw the resident fall on his right side after standing up using a front-wheeled walker. The resident was subsequently sent to a general acute care hospital for further evaluation. The resident had a history of falls and was known to have severely impaired cognition, requiring supervision or touching assistance when standing from a sitting position. Previous assessments, including a Minimum Data Set and a Physical Therapy Evaluation, indicated the need for supervision due to the resident's balance issues and decreased muscular coordination. Despite these documented needs, the resident was left unsupervised, leading to the fall and subsequent injury. Interviews with staff confirmed that they were not in close proximity to the resident at the time of the fall, which was contrary to the facility's policy on resident safety that required a person-centered observation system to address identified risk factors.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent two residents, both assessed at high risk for elopement, from leaving the facility unsupervised. Resident 1, who had fluctuating capacity to understand and make decisions and was diagnosed with suicidal ideation, eloped from the facility during a shift change. The resident climbed the roof from the facility's main patio, jumped into the parking lot, and climbed over the fence. This incident occurred despite the resident's care plan indicating a need for monitoring and supervision to prevent elopement. Resident 2, who had no capacity to understand and make decisions and was also diagnosed with suicidal ideations, eloped from the same location a week later. The resident used water pipes attached to the building to climb to the roof and escape. The facility's lack of dedicated staff to monitor the patio during the night shift contributed to this incident. The patio doors remained unlocked 24 hours a day, allowing residents to access the area freely, which further facilitated the elopement. The facility did not thoroughly investigate the first elopement incident to prevent a recurrence. Staff monitoring the breezeway and patio areas did not have a full view of the patio, and there was no dedicated staff assigned to monitor the patio during the night shift. Additionally, the facility's closed-circuit television did not cover the area where the residents climbed to the roof, and there was a lack of communication among staff regarding the residents' elopement risks.
Removal Plan
- Residents were monitored and supervised when in Patio 1 at all times, in all three shifts.
- Heightened awareness on security and oversight of all facility exit doors for all three shifts.
- Residents at risk for elopement are frequently monitored and their whereabouts are always accounted for.
- Staff were in-serviced on how to care for residents at risk for elopement.
- Measures are in place to prevent residents from leaving the facility unsupervised for 22 residents at risk for elopement.
- Police notified and missing person's report filed.
- Facility contacted local hospitals during every shift to locate the resident.
- Maintenance Staff removed clutter/items in Patio 1 that may potentially be used by the residents to gain access to climbing over the roof.
- Patio 1 was assigned 24-hour monitoring to ensure residents are monitored and supervised and for staff to be on the outer perimeter of Patio 1 on all three shifts when in Patio 1.
- Outgoing staff monitoring patio stays in Patio 1 until incoming staff to patio monitor arrives.
- During shift change, incoming and outgoing staff that monitors patio are to position themselves in a spot where they have clear vision of Patio 1 while they are endorsing to other staff.
- When the staff monitoring patio goes on break, a staff is assigned to relieve them prior to leaving Patio 1.
- Administrator contacted security agency to secure a contract for unarmed security to provide heightened awareness for security oversight of all facility exit doors and facility egress for all three shifts including supervision and monitoring of resident areas.
- Administrator secured a quote for fencing. The contractor is arriving to evaluate the area of concern on the identified area of fencing. A work order will be completed.
- Corporate policy committee will be consulted regarding a more updated Elopement policy.
- DON/Designees conducted an audit of the Elopement Binder to ensure that current residents that are at risk for elopement were included and had a photo identifier unless they refused to have their photo taken.
- Administrator/designee conducted an observation of the patio area (Patio 1) during the shift change to ensure that the patio is monitored, and residents were always supervised by the staff.
- Administrator and DON initiated an in-service education to RNs, Licensed Vocational Nurses (LVNs), CNAs, Rehabilitation and Activity staffs, Activities, Business Office, Dietary, Housekeeping, Laundry, Maintenance, Receptionist, Social Services, Medical Records staff regarding the facility's policy and procedures for Wandering and Elopement, with emphasis on the importance of having the patio area always supervised in all three shifts, caring for residents at risk for elopement, and recognizing changes in condition that may potentially increase the risk of residents leaving the facility unsupervised.
- DON initiated an in-service to the nursing staff regarding hourly monitoring of residents who are at risk for elopement. This will be documented on the 'Residents who are at Risk for Elopement Monitoring' form.
- CNAs will conduct room rounds hourly every shift to ascertain all residents are accounted for.
- The Elopement Binder is placed at each Nurses Station and are reviewed with staff during shift change for any concerns, changes, or new admissions. These binders are updated by the DON/Designee as needed.
- The ADM will be responsible for monitoring and sustaining compliance.
Failure to Develop Care Plan for Resident with Drug Abuse History
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of drug abuse and who was permitted to go out on pass. Despite the resident's history of schizophrenia, depression, and drug abuse, the facility did not include specific interventions in the care plan to monitor the resident's behaviors when going out on pass. The Director of Nursing (DON) acknowledged the absence of a documented care plan addressing the resident's history of drug use and the out on pass situation, stating that the facility had not initiated care plans for such scenarios. The resident's medical records indicated a history of schizophrenia, hypertension, hyperthyroidism, depression, and drug abuse, with a social history of smoking, alcohol, and methamphetamine use. The DON admitted that while there was verbal communication among staff regarding interventions for residents returning from out on pass, there was no written policy or care plan. The facility's policy on comprehensive person-centered care planning emphasized the need for interdisciplinary care to meet residents' health, safety, psychosocial, behavioral, and environmental needs, which was not adhered to in this case.
Failure to Investigate and Locate Missing Resident
Penalty
Summary
The facility failed to investigate and locate a resident who was at risk for elopement and had a history of suicidal ideations. The resident, who had fluctuating capacity to understand and make decisions, was transferred to a General Acute Care Hospital (GACH 2) for evaluation due to claims of abuse and pain. However, upon arrival at the hospital, the resident eloped from the ambulance and was not admitted to the hospital. The facility did not take immediate action to locate the resident after being informed that the resident was not admitted to GACH 2. The facility's Administrator (ADM) and Admission Coordinator (AC) were aware of the situation but did not follow up with the hospital or the ambulance company promptly. The ADM believed that the responsibility for the resident's whereabouts lay with the hospital since the resident had been discharged from the facility's care. The facility's Medical Records Director (MRD) was involved in a group text message with the physician and hospital liaison, where it was confirmed that the resident had eloped from the hospital. Despite this information, the facility did not report the incident to law enforcement or take further steps to locate the resident. The facility lacked a policy on ensuring a safe discharge or transfer of residents to other facilities. The existing policy on resident safety did not address the procedures for handling such situations. This deficiency in policy and the failure to act promptly upon learning of the resident's elopement contributed to the resident remaining missing, with potential risks to their safety.
Failure to Monitor and Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to monitor and supervise a resident who was identified and assessed at risk for elopement. The resident, who had diagnoses of unspecified psychosis, major depressive disorder, and dementia, eloped from the facility and was missing for an extended period. The resident was last seen in the facility's breezeway area and was later found at a nearby school football field the following day. The facility's staff did not have a scheduled monitor for the breezeway area, and the surveillance cameras were not continuously monitored during the day and evening shifts, contributing to the resident's ability to leave the facility undetected. The resident's elopement was discovered during a medication pass when the Licensed Vocational Nurse (LVN) could not locate the resident. A Code [NAME] was initiated, and local law enforcement was called for assistance. The facility staff conducted a search of the premises and the surrounding neighborhood but did not find the resident until the next morning. The resident was compliant and returned to the facility without injuries, stating that he left because he was hungry and did not know why he had left initially. Interviews with the facility's Administrator (ADM) and staff revealed that the breezeway area did not have assigned staff for monitoring, and the surveillance cameras were only continuously monitored during the night shift. The facility's policy on wandering and elopement indicated that residents at risk for elopement should be identified and measures taken to minimize injury, but these protocols were not effectively implemented in this case. The resident demonstrated how he had kicked open a locked door and climbed onto the roof to leave the facility, highlighting gaps in the facility's security and supervision measures.
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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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