Montrose Springs Skilled Nursing & Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Montrose, California.
- Location
- 2635 Honolulu Ave, Montrose, California 91020
- CMS Provider Number
- 056322
- Inspections on file
- 43
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Montrose Springs Skilled Nursing & Wellness Center during CMS and state inspections, most recent first.
Two residents receiving IV antibiotics for sepsis, UTI, and pneumonia had missing documentation on their IV therapy records for scheduled early-morning doses of meropenem and ampicillin. Physician orders required specific IV antibiotic regimens, but the IVT records did not show that these doses were administered, and the RN supervisor confirmed the lack of documentation and stated they should have been recorded. Facility policy required licensed nurses to follow the 6 rights of medication administration, including immediate documentation of time and dose on the MAR/IVT record, which was not followed in these instances.
A resident with diabetes and a left below-knee amputation, who required assistance with ADLs but had intact cognition, experienced an unwitnessed fall resulting in a facial abrasion. Facility policy required 72-hour neurochecks after an unwitnessed fall with suspected head injury, on a defined schedule from every 15 minutes to every 4 hours. Record review and staff interviews showed multiple required neurochecks were missing and two were performed late, with no physician order to discontinue the monitoring. A family member reported being told the resident did not hit their head, later observed a facial abrasion, and expressed concern about the accuracy of the post-fall assessment.
A resident with hepatic encephalopathy, dysphagia, and moderate cognitive impairment experienced a fall resulting in a forehead laceration; EMS was called and the wound was treated, but there was no documentation that the physician or family were notified of the fall and injury. Subsequently, a physician ordered ROM and ambulation with a front wheel walker three times weekly, yet the restorative treatment record showed no treatments provided over several consecutive days. The RNA stated the resident had not been feeling well and refused the exercises, but there was no documentation that the physician was informed of these refusals.
Two residents with limited English proficiency and documented preferences for interpreter services did not have person-centered care plans addressing their communication needs, despite MDS assessments and facility policies requiring identification and care planning for communication requirements. One resident with DM, muscle weakness, and colorectal cancer reported not being fluent in English and needing help to communicate needs, while another resident with hepatic encephalopathy, dysphagia, and cognitive communication deficit could not effectively express concerns, including that his television was not working and available programming was not in a language he understood. The MDS coordinator confirmed that no communication-focused care plans were developed for either resident.
A resident with DM and cognitive impairment had physician orders for Glipizide and Metformin, with fasting blood sugar checks required before breakfast and at bedtime, and instructions to notify the physician if levels were below 70 or above 400. On one morning, the ordered fasting blood sugar was not obtained or documented before the resident received the scheduled oral hypoglycemic medications. The DON confirmed the blood sugar should have been checked prior to administration and that lack of documentation indicated it was not done. This failure was inconsistent with the resident’s diabetes care plan and the facility’s medication administration policy requiring completion and recording of ordered testing, such as point-of-care blood glucose, before giving medications dependent on such results.
A resident with multiple cardiac conditions and diabetes was ordered numerous oral medications and a clonidine patch but persistently refused all medications except the patch over an extended period. The existing care plan for medication refusal contained only basic interventions such as assessing reasons for refusal, documenting refusals, encouraging compliance, and notifying the MD for complications, and it was not updated with new, specific, or measurable interventions despite continued noncompliance. IDT meetings did not reassess or address the ongoing refusals, nursing staff limited their response to repeated education and documentation, the RN supervisor did not involve the pharmacist and had minimal documented MD communication, and the administrator was unaware of the persistent refusals, contrary to the facility’s own person-centered care planning policy.
A nurse administered seven scheduled morning medications, including an antiepileptic, antihypertensive, antidepressant, vitamin D, iron supplement, stool softener, and multivitamin, to a resident more than one hour after the ordered 9:00 AM time, outside the facility’s 8:00–10:00 AM administration window. The RN supervisor reported that nurses typically have about 30 residents and roughly 5 minutes per resident for the morning med pass, which can extend beyond the 2-hour window, and the LVN involved acknowledged the medications were late due to unforeseen events on the unit, contrary to the facility’s policy requiring adherence to the “Right Time” for medication administration.
Surveyors observed that several opened dry food items in the kitchen, including powdered cheese, gelatin mix, cake mix, breadcrumbs, and coconut flakes, were not labeled with opened dates or were stored beyond recommended timeframes. The Registered Dietitian confirmed that facility policy requires labeling and timely disposal of such items, but these procedures were not followed, resulting in improper food storage practices.
A resident with significant physical and cognitive impairments was assisted with feeding by a CNA who stood over the resident instead of sitting at eye level, as required by facility policy. The CNA reported not using a chair due to its unavailability, and both the CNA and an RN confirmed that proper feeding assistance should be provided while seated to maintain resident dignity and comfort.
A resident with dementia and anxiety disorder was prescribed Ativan, a psychotropic medication, without documented informed consent as required by facility policy. Despite the resident's capacity to make decisions, staff confirmed that no signed consent form was present in either the paper or electronic health records, constituting a violation of resident rights and facility procedures.
A resident with multiple medical conditions and intact cognition repeatedly raised concerns about poor Wi-Fi connectivity affecting personal device use. Despite facility acknowledgment and some steps toward resolution, there was a lack of timely follow-up and communication with the resident, and no clear explanation for the delay in installing Wi-Fi extenders. This resulted in the resident's grievance remaining unresolved and affected their quality of life.
A resident with severe cognitive impairment and fluctuating decision-making capacity did not have an Advance Directives Acknowledgement Form or POLST present in their hard copy medical record. Multiple staff, including the SSD, RN Supervisor, and DON, confirmed the absence of these documents, despite facility policy requiring their provision and accessibility.
Two residents did not receive comprehensive, person-centered care plans following significant changes in their conditions and medication regimens. One resident with abdominal pain and moderate cognitive impairment was not provided a care plan after a change in condition, and another resident prescribed Depakote for behavioral issues did not have a care plan addressing medication use, monitoring, or side effects. Staff and leadership confirmed these omissions, which were not in accordance with facility policy.
A resident with quadriplegia and severe cognitive impairment was left without required supportive devices, such as pillows or wedges, after morning care. The resident was observed in an uncomfortable position, and staff interviews confirmed that proper positioning and support were not provided as outlined in the care plan and facility policy.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These failures resulted in a deficiency related to resident care.
A resident with severe cognitive impairment, dysphagia, and malnutrition, who required moderate assistance with eating, did not receive proper mealtime support from a CNA. The resident was left to manage a mechanical soft diet tray without necessary help, such as cutting food or ensuring items were within reach, contrary to care plan and facility policy requirements. Staff interviews and observations confirmed the lack of appropriate assistance.
The facility did not provide necessary medically-related social services to a resident, resulting in the resident not achieving the highest possible quality of life.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A deficiency was cited when it was found that a working call system was not available in each resident's bathroom and bathing area, preventing residents from being able to request assistance as needed.
Two residents experienced deficiencies in fall prevention when staff failed to follow established care plan interventions and facility policies. One resident with severe cognitive impairment was left unattended during toileting, resulting in an unwitnessed fall and injury requiring hospital treatment. In another case, after a resident's fall and readmission, there was no documentation of an IDT review as required by policy. These failures led to inadequate supervision and lack of proper post-fall evaluation.
Surveyors found that several rooms in the facility housed more than four residents per room, with some rooms containing five or six beds and being fully occupied. Although residents reported no concerns about space and rooms were equipped with necessary furniture and equipment, the facility did not comply with federal regulations limiting room occupancy.
Eighteen resident rooms were found to be below the required 80 square feet per resident in multiple occupancy rooms, as confirmed by the ADM and documented in facility records. Despite the deficiency, no concerns were raised by residents or observed by surveyors, and the facility continues to seek a waiver for these rooms.
A resident with adult failure to thrive and Alzheimer's disease was admitted with an NPO order due to inability to swallow, but the care plan did not reflect this dietary restriction. Both an RN and the DON confirmed the omission, despite facility policy requiring care plans to include physician and dietary orders within 48 hours of admission.
A resident with severe cognitive impairment and total dependence for care was subjected to rough perineal care by a CNA, resulting in pain and distress. Despite reports from the responsible party and a roommate who witnessed and heard the resident in distress, facility staff did not immediately remove the CNA from the assignment or report the incident as potential abuse. The resident's care plan interventions were not followed, and mandated reporting procedures were not implemented, leading to further distress for the resident and fear for another resident.
A resident with severe cognitive impairment and multiple medical conditions was allegedly treated roughly by a CNA during peri care, as witnessed by the responsible party and corroborated by a roommate. Despite the allegation being reported to facility staff, required notifications to CDPH, the Ombudsman, and Law Enforcement were not made within the mandated timeframe, and the CNA continued to provide care to the resident. Staff failed to recognize and escalate the incident as abuse, and the facility did not initiate an investigation or remove the CNA from duty until after law enforcement was contacted.
A resident with severe contractures and arthritis was roughly handled by a CNA during care, resulting in a fracture and hospitalization. Despite the resident's complaints and visible injuries, the facility failed to promptly report the abuse allegation or suspend the CNA. The DON initiated an investigation but did not interview the CNA or follow the facility's abuse prevention and reporting policies.
A facility failed to ensure proper discharge planning for a resident with Parkinson's Disease and Dementia, resulting in the resident not receiving necessary home health services and durable medical equipment after discharge. The Social Service Director and Case Manager did not coordinate effectively, leading to a lack of follow-up on required services and equipment.
The facility failed to complete and document the Annual Certified Nurse Assistant (CNA) Core Clinical Competencies (ACCC) for eight CNAs. The DON admitted there was no system to track performance evaluations, and CNAs could not recall their last skills assessment. A review of employee files showed no ACCC documentation, and only partial skills competencies were evidenced, contrary to facility policy.
A facility failed to inform a resident about medications before administration, violating their rights. An LVN administered medications, including laxatives, without informing the resident, who had expressed a preference against laxatives. Additionally, the facility failed to account for six doses of controlled substances for four residents, with discrepancies found in medication records. The LVN admitted to administering these medications but did not document them, violating facility policy and increasing the risk of medication errors.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 5.71% due to two errors affecting two residents. One resident received the wrong form of calcium, and another received a multivitamin with minerals instead of the prescribed type. LVNs acknowledged the errors, and the DON confirmed the medications were not administered as ordered.
The facility failed to remove expired medications from stock in one of its medication rooms. An open vial of Aplisol was found without a label indicating when it was opened, and 15 expired Afluria syringes were stored in the refrigerator. Interviews with staff confirmed these medications should have been discarded according to facility policies.
A kitchen staff member was inadequately trained on the proper use of sanitizer test strips, leading to incorrect testing of a QUAT sanitizer solution. The staff member initially used the wrong test strip and did not follow the correct procedure, resulting in an inaccurate reading. The issue was identified during an observation, and it was noted that the facility's training did not cover the correct testing procedure.
The facility failed to follow the prescribed portion sizes for residents on pureed and mechanical soft diets during a lunch service. Residents on a pureed diet received less chicken than required, and those on a mechanical soft diet received less zucchini. The error was due to the use of incorrect scoop sizes by the cooks, as confirmed by the RD.
Two residents with severe cognitive impairments were fed by CNAs standing over them, violating their dignity. The CNAs admitted they should have been at eye level, as confirmed by facility staff and policy.
The facility failed to ensure call lights were within reach for two residents, both with severe cognitive impairments and mobility issues. One resident had the call light tied to the bedrail, out of reach, while another had it placed on the side of the bed inaccessible to their functional hand. Staff interviews confirmed the importance of having call lights accessible, as per facility policy.
A resident with a history of hypertension, obesity, and diabetes exhibited redness in both eyes, which was not reported to the physician by the LTC facility staff. Despite the redness being observed by an LVN for several days, it was assumed to have been documented, leading to a delay in care. The facility's policy requires notifying the physician of such changes, but this was not adhered to, resulting in a deficiency.
A resident with severe cognitive impairment was left exposed during personal care when a CNA failed to pull the privacy curtain, despite the presence of a roommate. The facility's policy requires privacy to be maintained to preserve resident dignity.
The facility failed to develop comprehensive care plans for two residents, leading to potential inadequate care. One resident with multiple diagnoses, including diabetes and cataracts, had no care plan for eye redness despite physician orders. Another resident with an inguinal hernia lacked a care plan for its management, affecting his eating due to abdominal discomfort. The absence of care plans was confirmed by nursing staff and contradicted facility policy requiring updates for new problems or changes in condition.
A facility failed to update a care plan for a resident who experienced bladder incontinence after a urinary catheter was removed. The resident, with dementia and psychosis, was at risk of UTIs due to inconsistent care. Staff interviews confirmed the care plan should have been revised to address the incontinence.
A resident with morbid obesity and hemiplegia was at risk for pressure ulcers due to the facility's failure to set the Low Air Loss (LAL) mattress according to the physician's order. The mattress was set for a lower weight than the resident's actual weight, as confirmed by staff observations and interviews. This oversight could lead to skin breakdown, contrary to the facility's policy requiring proper mattress settings based on weight.
A resident with an indwelling catheter was found with the catheter unsecured and the catheter bag touching the floor, contrary to the facility's policy. An LVN confirmed the bag should not touch the floor, and the DON acknowledged the issue, stating that RNs were informed to secure the catheter and keep the bag off the floor.
The facility failed to provide proper respiratory care for two residents. One resident's nasal cannula was improperly placed, and another resident received incorrect oxygen flow and lacked proper labeling of the nasal cannula. Additionally, the second resident's oxygen saturation was not documented, and they were without oxygen for 15 minutes during ADL assistance.
A resident with arthritis and dementia experienced severe pain without proper assessment or timely medication in an LTC facility. Despite a physician's order for regular pain assessments and medication, the resident was left in distress, and the LVN failed to document or reassess pain levels. The facility's policy on pain management was not followed, leading to delayed care.
A resident with an inguinal hernia expressed a desire for surgery, but the LTC facility failed to follow up on the surgery plan, despite the resident's intact cognition and capacity to make medical decisions. The facility did not document any attempts to contact the physician or obtain necessary oncologist clearance, leading to a deficiency in care.
The facility failed to implement its infection control program effectively, leading to several deficiencies. Unlabeled urinals and wash basins were found in a shared restroom, and two residents had unlabeled urinals at their bedside tables, posing a risk of cross-contamination. Additionally, a CNA provided care to a resident with a foot wound without wearing an isolation gown, despite the resident's risk of infection. The facility lacked specific policies and procedures to ensure proper labeling and use of protective equipment.
A resident's shared bathroom in an LTC facility was found to have a non-functioning call light, which is crucial for safety and emergency communication. The resident, who requires substantial assistance due to severe cognitive impairment and limited mobility, was unaware of the issue. The Director of Staff Development confirmed the deficiency, and the Maintenance Staff noted that no reports of defective call lights were made this month, despite the facility's policy requiring immediate reporting and replacement of such issues.
The facility did not post the daily nurse staffing information in a prominent place accessible to residents and visitors. The Director of Staff Development updated the information, but the Administrator forgot to post it, resulting in outdated information being displayed. The facility's policy requires staffing data to be posted at the beginning of each shift.
The facility was found non-compliant with federal regulations limiting the number of residents per room during a recertification survey. Eight rooms exceeded the four-resident limit, with some rooms having up to six beds. The Administrator acknowledged the issue, citing room waivers, but surveyors noted potential impacts on privacy and care quality. Residents did not express concerns about room sizes during interviews.
The facility failed to meet the required 80 square feet per resident in multiple resident bedrooms, affecting 18 out of 41 rooms. Despite having room waivers, the facility's Client Accommodation Analysis showed several rooms with insufficient space. Observations indicated that care was not hindered, and no concerns were raised by the resident council.
The facility failed to treat two residents with respect and dignity by not honoring their preferences and choices regarding ADLs. One resident experienced a fall and injury after CNAs forcibly changed her diaper against her will, while another resident reported physical pain and distress from a similar incident. These actions contradicted the facility's policy on resident rights.
Failure to Accurately Document IV Antibiotic Administration for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for two residents receiving IV antibiotics. For the first resident, who had sepsis due to E. coli, UTI, ESBL, pneumonia, fluctuating decision-making capacity, and moderate cognitive impairment, the physician’s order directed meropenem 1 g IV three times daily until a specified end date. Review of the IV Therapy Administration Record for the month showed no documentation that the meropenem dose scheduled for 6 AM on 3/24/2026 was administered. The Registered Nurse Supervisor (RNS) stated that after a medication is administered, the licensed nurse must document it to prove it was given, and that without documentation there is no proof the dose was not missed. For the second resident, who was admitted with sepsis, E. coli, and UTI and was documented as alert, oriented, and with normal cognition, the physician’s order directed ampicillin sodium 2 g IV every six hours for six days for sepsis secondary to E. coli UTI. Review of this resident’s IV Therapy Administration Record for the month showed no documentation that the ampicillin dose scheduled for 6 AM on 4/15/2026 was administered. During concurrent interview and record review, the RNS confirmed that the IVT Medication Record did not show documentation of the 6 AM dose and stated it should have been documented. The facility’s medication administration policy required that all medications be administered by licensed nursing staff according to provider orders and that the “right documentation” be completed immediately after administration. The policy specified that the time and dose of medication or treatment administered must be recorded in the resident’s individual medication record by the person who administers it. In both residents’ cases, the IVT records lacked documentation for ordered IV antibiotic doses at specific times, contrary to the facility’s policy and accepted standards for complete and accurate medical records. The RNS stated that if the full antibiotic course is not received and documented, follow-up diagnostics such as chest x‑ray may not show resolution of infection.
Failure to Complete and Document Required 72-Hour Neurochecks After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to consistently perform and document 72-hour neurological checks as required by its Fall Management Program policy after an unwitnessed fall with suspected head injury. The resident involved had a history of type 2 diabetes mellitus and a left below-knee amputation, was originally admitted in 2017 and later readmitted, and had intact cognition and memory per a recent MDS. The MDS also showed the resident required supervision or touching assistance with eating and oral hygiene, and partial/moderate assistance with toileting, bathing, lower body dressing, and transfers. On the date of the incident, progress notes documented an unwitnessed fall in the early morning and a change in condition evaluation confirmed the fall. Later that morning, progress notes documented an abrasion on the right side of the resident’s face following the fall. Review of the neurological check lists and interviews with the MDS nurse and an RN showed that the required 72-hour neurocheck schedule was not followed or fully documented. The facility’s policy required neurochecks every 15 minutes for one hour, every 30 minutes for two hours, every hour for four hours, and then every four hours for 65 hours after an unwitnessed fall with suspected head injury. However, there was no documentation of neurochecks at specific required times, including on one date at 1 PM and on the following date at 1 AM and 5 AM. The RN also identified that two neurochecks due at 5 PM and 9 PM were instead performed and documented at 5:46 PM and 10:53 PM, indicating delays. There was no physician order to discontinue the 72-hour neurochecks, and the MDS nurse stated that if a neurocheck was not documented, it was considered not done. A family member reported being told the resident did not hit his head, but later observed an abrasion on the resident’s face and was concerned about the accuracy of the assessment after the fall.
Failure to Notify Physician/Family After Fall and to Provide Ordered Restorative Therapy
Penalty
Summary
The deficiency involves the facility’s failure to notify the attending physician and the responsible party after a resident sustained a fall with a resulting laceration, and failure to carry out and report refusals of ordered restorative treatments. The resident was admitted with hepatic encephalopathy, dysphagia, and a cognitive communication deficit, and an MDS dated 2/19/2026 documented moderately impaired cognition and a need for supervision or partial/moderate assistance with multiple ADLs, including toileting hygiene, bathing, dressing, eating, oral hygiene, and personal hygiene. On 2/18/2026, progress notes documented that the resident was found on the floor with a forehead cut measuring 2.0 x 0.1 cm, 911 was called, EMS determined there were no significant injuries requiring hospital transport, and the wound was cleansed and monitored. However, in the change in condition fall note for that date and time, there was no documentation that the physician or family were notified of the fall and injury. On 2/23/2026, a telephone/verbal physician order was obtained for a Restorative Nurse Assistant to perform active ROM to both upper extremities and ambulation with a front wheel walker three times weekly for three months. Review of the restorative treatment record from 2/23/2026 through 2/26/2026 showed blanks, indicating that no restorative treatments were provided during that four-day period. During interviews, the resident reported wanting to get out of bed but feeling that his legs were heavier and that he felt tired, and the RN supervisor stated the resident was being monitored for fluid retention. The RNA reported that she had not performed the ROM and ambulation treatments because the resident had not been feeling well on those days, and there was no documentation that the physician was notified of the resident’s refusals of the ordered restorative exercises.
Failure to Care Plan for Non‑English Communication Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered care plans addressing communication needs in residents whose preferred language was not the dominant language used in the facility. For one resident admitted with diagnoses including diabetes mellitus, muscle weakness, and malignant neoplasm of the large intestine and rectum, the admission record and MDS identified a preferred non-dominant language and a desire for an interpreter to communicate with doctors and health care staff. During interview, this resident reported understanding only some English words, not being fluent, and needing assistance to communicate needs. Observation showed a RN Supervisor using another licensed nurse to translate in the resident’s primary language, and the resident stated he could not communicate his needs in English. Despite this, the MDS coordinator confirmed there was no person-centered care plan developed to address this resident’s communication limitations and need for services in the preferred language. The second resident was admitted with hepatic encephalopathy, dysphagia, and a cognitive communication deficit, and the MDS documented moderately impaired cognition and the need for supervision or assistance with multiple ADLs. Progress notes indicated this resident also needed and wanted an interpreter to communicate with doctors or health care staff. During interview conducted in the resident’s primary language, the resident stated he could not make himself understood and could not fluently understand the language spoken in the facility, and he was unable to explain to staff that his television did not work and that the only audible channel was not in a language he understood. The MDS coordinator acknowledged that, based on the MDS information, both residents should have had person-centered care plans reflecting their communication limitations and language needs, but no such care plans existed. This failure occurred despite facility policies on accommodation of residents’ communication needs and resident rights, which required identification of communication requirements, documentation of preferences, and inclusion of these needs and interventions in the plan of care.
Failure to Check Blood Glucose Prior to Administering Hypoglycemic Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with a physician’s order for monitoring blood glucose prior to administering hypoglycemic medications. A resident with diagnoses including Diabetes Mellitus, muscle weakness, and malignant neoplasm of the large intestine and rectum was admitted on 2/6/2026. The resident’s MDS dated 2/13/2026 documented moderately impaired cognition and the need for varying levels of assistance with activities of daily living. Telephone/verbal orders dated 2/7/2026 directed that the resident receive Glipizide 2.5 mg and Metformin 500 mg twice daily with meals, with fasting blood sugar checks ordered before breakfast at 6:30 AM and at bedtime at 9:00 PM, and instructions to call the physician if blood sugar was less than 70 or greater than 400. The resident’s care plan for diabetes, dated 2/7/2026, indicated the resident would be free from signs and symptoms of hypoglycemia. Review of the Medication Administration Record for 2/7/2026 showed that the fasting blood sugar ordered for 6:30 AM was not documented as completed prior to medication administration, and the DON confirmed that if it was not marked on the MAR, it was not done. The MAR further showed that the resident received Metformin 500 mg twice daily with meals and Glipizide 2.5 mg at 9:00 AM on 2/7/2026 without a recorded blood glucose check beforehand. The DON stated that the blood sugar should have been checked in the morning prior to medication administration as ordered and explained that when the order was entered, it was timed to begin at 9:00 PM and not before breakfast. The facility’s medication administration policy, revised 6/26/2025, stated that when medication administration is dependent on vital signs or testing, such as point-of-care blood glucose, the testing must be completed and recorded prior to administration, which did not occur in this instance.
Failure to Revise Care Plan for Ongoing Medication Refusal
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, resident-centered care plan with specific, measurable objectives and interventions for a resident who persistently refused medications. The resident had multiple significant cardiac and metabolic diagnoses, including atherosclerotic heart disease, hypertensive heart disease with heart failure, cardiomyopathy, and type 2 diabetes mellitus, and was ordered 15 active medications (14 oral and 1 clonidine transdermal patch). Despite this complex regimen, the resident repeatedly refused most medications over an extended period, taking only the clonidine patch, while remaining alert, oriented, and frequently going out on pass with a family member. The resident’s care plan for medication refusal, initiated on 6/30/25 and revised on 7/29/25 and 10/14/25, contained only four original interventions: assess the reason for refusal, document refusals and actions taken, encourage medication compliance with explanation of risks and benefits, and notify the physician for complications. No new or modified interventions were added despite ongoing, documented noncompliance with medications. Physician notes over several months documented that the resident was noncompliant with blood pressure medications except the clonidine patch and remained noncompliant with medications and care despite education on risks. The electronic MAR for January 2026 showed the resident refused all medications except the clonidine patch for the entire review period. Interdisciplinary team (IDT) meeting notes showed that while the resident’s medication refusal was noted on 6/30/25, subsequent IDT meetings did not include discussion or reassessment of this issue. Nursing staff reported that when the resident refused medications, they provided education, documented the refusal, and informed the nursing supervisor, but the RN supervisor acknowledged there were no additional interventions or assessments beyond re-education and documentation. The RN supervisor also stated she had not contacted the pharmacist to investigate potential medication-related issues contributing to the refusals and had limited documented communication with the physician, with the last recorded contact several months earlier. The administrator stated she was not aware of the resident’s ongoing medication refusals. The facility’s own person-centered care planning policy required the IDT to prepare, review, and revise the comprehensive care plan and to implement interventions designed to meet resident objectives, which was not carried out in this case.
Late Administration of Scheduled Morning Medications Beyond Allowed Time Window
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered within the facility’s required time window for one resident. During an observation, an LVN was seen preparing and administering a group of seven scheduled medications for a resident, including docusate sodium 100 mg, escitalopram 10 mg, levetiracetam (Keppra) 500 mg, losartan 50 mg, a multivitamin with minerals, vitamin D3 125 mcg (5000 IU), and ferrous sulfate 325 mg. The resident was seated in a wheelchair while the LVN measured the resident’s blood pressure and then prepared and administered the medications. The administration occurred at approximately 11:00 AM, even though the medications were scheduled for 9:00 AM, placing the administration more than one hour after the scheduled time. Interviews with staff confirmed that the facility’s policy required medications to be administered within one hour before or one hour after the scheduled time, and that nurses were to follow the “Right Time” as part of the six rights of medication administration. The RN supervisor stated that morning medications were scheduled at 9:00 AM with an 8:00 AM to 10:00 AM administration window, and acknowledged that with an average assignment of 30 residents per nurse and approximately 5 minutes per resident, some medication passes could extend beyond the 2-hour window. The LVN who administered the medications acknowledged awareness that the medications for this resident were late and attributed the delay to unforeseen events on the unit. The facility’s written policy confirmed the requirement to administer medications within the ordered time window, which was not met in this instance.
Failure to Properly Label and Store Dry Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to its own policies and procedures regarding the storage and labeling of dry food items in the kitchen's dry storage area. During an observation with the Registered Dietitian (RD), several food items, including a bag of powdered cheese, gelatin mix, chocolate cake mix, breadcrumbs, and coconut flakes, were found either without an opened date or stored beyond the recommended storage period. Specifically, a bag of dried cheese powder dated 3/28/2025 was found to have exceeded its storage period, and multiple opened food items lacked labels indicating when they were opened. The RD confirmed that these items should have been dated upon opening to ensure proper rotation and timely disposal. Additionally, inconsistencies were noted between the delivery/received dates on storage bins and the individual food packages inside the bins, such as with pasta. The facility's policy requires that opened products be placed in containers with tight-fitting lids, labeled, and dated, and that stock be rotated according to specific timeframes for each product. The RD acknowledged the importance of correct dating for maintaining food quality and knowing when to discard items. These lapses in following established food storage guidelines had the potential to affect 113 out of 117 residents who receive food from the kitchen.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) provided feeding assistance to a resident while standing over the resident, rather than sitting at eye level as required by facility policy. The resident, who had contractures in both hands, dysphagia, unspecified dementia, and was on a mechanically altered, pureed, nectar thick diet, was observed lying in bed with the head of the bed elevated during the feeding. The CNA stated that a chair was not used because one could not be found, resulting in the CNA feeding the resident while standing. The CNA acknowledged that staff are expected to sit at eye level with residents during feeding to avoid making them feel rushed and to maintain dignity. Interviews with the CNA and a registered nurse confirmed that the standard practice is for staff to be seated and at eye level with residents during meals to promote communication, ensure comfort, and uphold the resident's dignity. Facility policy also requires staff to interact with residents in a manner that accommodates their physical limitations and maintains their dignity. The failure to follow these procedures during mealtime assistance for this resident constituted a lack of respect and dignity, as required by resident rights regulations.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to obtain informed consent for the administration of a psychotropic medication, Ativan, for a resident diagnosed with dementia and anxiety disorder. The resident was assessed as having the capacity to understand and make decisions, with moderately impaired cognition noted in the Minimum Data Set. Despite a physician's order for Ativan to be administered twice daily for anxiety, a review of both the paper and electronic health records revealed that no informed consent form for the use of Ativan was present for the relevant period. Both the Medical Records staff and the Registered Nurse Supervisor confirmed the absence of the required documentation, and the Director of Nursing also verified that the consent form could not be located in the resident's records. Facility policy required that informed consent be obtained and documented before administering psychoactive medications, with written consent to be renewed every six months. The lack of a signed and dated consent form for the psychotropic medication was acknowledged by staff as a violation of resident rights and a failure to follow established procedures. The deficiency was identified through interviews, record reviews, and policy examination, all confirming that the necessary informed consent process was not completed or documented as required.
Failure to Resolve Resident Grievance Regarding Wi-Fi Connectivity
Penalty
Summary
The facility failed to promptly address and resolve a grievance raised by a resident regarding the need for Wi-Fi extenders to improve connectivity for personal devices, such as a phone and television. The resident, who had diagnoses including congestive heart failure, hypertension, and anemia, and was cognitively intact, repeatedly brought up the issue during Resident Council Meetings and directly to the administrator. Documentation showed that the facility acknowledged the request and initiated discussions with IT and maintenance, including obtaining equipment and seeking vendor quotes for installation. However, there was a lack of timely follow-up and communication with the resident about the status of the installation, and no rationale was provided to the resident for the delay. Interviews with the resident and staff confirmed ongoing difficulties with Wi-Fi connectivity, affecting both residents and staff operations. The administrator was unable to provide documentation of interactions with maintenance or evidence of follow-up with the resident regarding the unresolved grievance. The facility's policy required the administrator, as the Grievance Official, to ensure timely follow-up and provide written decisions upon request, but this process was not completed, resulting in the resident's grievance remaining unresolved and impacting the resident's quality of life.
Failure to Maintain Accessible Advance Directives and POLST in Resident Record
Penalty
Summary
The facility failed to ensure that the Advance Directives Acknowledgement Form and the Physician Orders for Life-Sustaining Treatment (POLST) were obtained and readily accessible in the hard copy medical record for one resident. During a review of the resident's admission record, it was noted that the resident had diagnoses including bipolar disorder and paranoid schizophrenia, with documentation indicating fluctuating capacity to understand and make decisions. The resident's Minimum Data Set assessment also showed severely impaired cognition. Despite these factors, both the Social Services Designee and the Registered Nurse Supervisor confirmed during interviews and record reviews that the advance directive acknowledgement form and POLST were not present in the resident's medical record. The Director of Nursing also acknowledged that these documents must be readily accessible in the resident’s hard copy medical record to guide licensed nurses in providing care according to the resident’s wishes during emergencies. The facility’s policy and procedures require that written information about advance directives be provided upon admission, but this was not reflected in the resident’s record. The absence of these critical documents was directly observed and confirmed by multiple staff members during the survey.
Failure to Develop Comprehensive Care Plans for Residents with New Conditions and Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to individualized care. For one resident with a history of abdominal pain, GERD, and Type 2 Diabetes Mellitus, the facility did not create a care plan to address new onset abdominal pain, despite documentation of moderate pain and a physician's order for hospital transfer. The resident had moderate cognitive impairment and required significant assistance with daily activities. Staff interviews confirmed that a care plan should have been implemented following the change in condition, but none was created, and the facility's policy requiring care plan updates after changes in condition was not followed. Another resident, admitted with diagnoses including Type 2 Diabetes Mellitus, diabetic neuropathy, depression, and bipolar disorder, was prescribed Depakote for poor impulse control and verbal aggression. Physician orders required monitoring for medication side effects and target behaviors. However, no care plan was initiated to address the use of Depakote, its intended purpose, or the monitoring of its effectiveness and side effects. Staff interviews confirmed the absence of a care plan for this medication, despite facility policy mandating comprehensive care plans for each resident that include measurable objectives and timeframes for meeting medical, nursing, mental, and psychosocial needs. The facility's failure to develop and update care plans in response to changes in condition and new medication orders resulted in incomplete documentation and a lack of individualized interventions for the residents involved. Staff and leadership acknowledged these omissions and confirmed that facility policies and procedures were not followed in these instances.
Failure to Provide Supportive Devices for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when staff failed to provide necessary supportive devices, such as pillows or wedges, for a resident with quadriplegia and multiple sclerosis, as required by the resident's care plan and the facility's policy. The resident, who was severely cognitively impaired and dependent on staff for all mobility and positioning, was observed lying in bed with the upper and lower body facing opposite directions and without any supportive devices in place. After morning ADL care, the CNA left the room without ensuring the resident was positioned comfortably or with proper support. Interviews with the LVN and Director of Nursing confirmed that the resident was not in a comfortable or appropriate position and that supportive devices were necessary due to the resident's limited mobility and inability to reposition independently. The facility's policy required staff to maintain good body alignment and provide proper equipment to redistribute pressure and support extremities and the head, which was not followed in this instance.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Failure to Provide Adequate Mealtime Assistance for Resident Requiring Moderate Support
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) failed to provide adequate nutritional care and services to a resident who required moderate assistance with eating. The resident, admitted with diagnoses including dysphagia, severe protein-calorie malnutrition, and dementia, was assessed as having severely impaired cognition and needing moderate assistance for activities of daily living, including eating. The care plan and physician orders specified a mechanical soft diet and interventions such as monitoring and anticipating the resident's needs. Despite these documented requirements, observations showed that the resident's breakfast tray was placed in front of her without necessary assistance, such as cutting bread into smaller pieces or ensuring all items were within reach. The resident was seen struggling to cut her food and unable to access her snack and water without help. Interviews with staff confirmed that the CNA did not provide the required assistance, such as cutting food and setting up the tray appropriately, as outlined in the resident's care plan and facility policy. The facility's policy required nursing staff to provide assistance to residents who have difficulty feeding themselves, but this was not followed in the case of this resident. The failure to provide the necessary support was directly observed and corroborated by staff interviews and record reviews.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that indicated the required social services were not made available or delivered to residents as needed. The lack of these services directly impacted the residents' ability to attain or maintain their optimal well-being.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify particular actions or inactions by staff, nor does it mention specific residents or incidents, but it clearly notes the absence or inadequacy of an infection prevention and control program.
Non-Functioning Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that residents did not have access to a functioning means to request assistance while in these locations. The report specifically notes the absence of a working call system, but does not provide additional details about individual residents, their medical history, or their condition at the time of the deficiency.
Failure to Follow Fall Management Policies and Provide Adequate Supervision
Penalty
Summary
The facility failed to follow its own policies and procedures regarding fall prevention and management for two residents, resulting in deficiencies related to accident hazards and inadequate supervision. For one resident with Alzheimer's disease and severe cognitive impairment, the care plan required that the resident not be left unattended during toileting. However, a CNA left the resident alone in the restroom with the door closed for privacy, contrary to the care plan. This lack of supervision led to an unwitnessed fall, resulting in a laceration to the right brow bone, abrasions, and the need for transfer to an acute care hospital for further treatment, including sutures. The facility also failed to update the resident's fall risk assessment after the incident and did not document all interventions recommended by the interdisciplinary team (IDT) following the fall. In the case of another resident with a history of sepsis, diabetes with neuropathy, and muscle weakness, the facility did not ensure that an IDT meeting was conducted after the resident sustained a fall and was readmitted to the facility. The resident was assessed as high risk for falls, and the care plan included frequent safety monitoring and fall risk precautions. Despite this, there was no documentation of an IDT meeting or review of the fall, as required by the facility's fall management policies. The absence of this review meant that the circumstances of the fall and the effectiveness of the care plan interventions were not evaluated by the IDT. Both cases demonstrate that the facility did not adhere to its established fall management programs, which require timely updates to care plans, post-fall assessments, and IDT reviews after falls. The failure to implement and document these interventions and reviews resulted in residents being left at risk for further accidents and injuries, as evidenced by the unwitnessed fall and subsequent injury in one resident and the lack of post-fall IDT review in another.
Resident Rooms Exceed Maximum Occupancy Requirements
Penalty
Summary
The facility failed to ensure that resident bedrooms accommodated no more than four residents per room, as required by federal regulations. During a recertification survey, it was observed that eight rooms contained either five or six beds, with several of these rooms fully occupied. The Client Accommodation Analysis and direct observations confirmed that these rooms exceeded the maximum occupancy limit. The surveyors noted that all rooms in question had individualized beds, bedside tables, overbed tables, and resident care equipment, and residents did not report concerns about room size or space during interviews. Despite the presence of adequate space for beds and equipment, the facility's practice of housing more than four residents per room in multiple-resident rooms did not comply with federal requirements. The facility had submitted a waiver letter and had policies in place for management to observe and ensure rooms met residents' needs without adversely affecting health and safety. However, the survey findings indicated that the number of beds and occupants in these rooms exceeded the regulatory limit, constituting a deficiency.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 18 out of 41 resident rooms met the minimum required space of 80 square feet per resident in multiple occupancy rooms. This was identified through observation, interviews, and record review during a recertification survey. The Administrator confirmed that these rooms did not meet the required square footage and stated the facility's intention to continue applying for a room waiver for these rooms. The Client Accommodation Analysis documented the specific square footage per resident for each deficient room, all of which fell below the regulatory requirement. During the survey, the rooms were observed and no immediate issues related to room size were identified. A review of the facility's Room Waiver Request Letter confirmed the ongoing deficiency and stated that the room sizes did not adversely affect residents' health and safety. Additionally, a group interview with the resident council revealed no concerns from residents regarding room sizes. The California Department of Public Health recommended continuation of the facility's room waiver.
Failure to Initiate NPO Care Plan for Resident
Penalty
Summary
The facility failed to initiate a care plan reflecting a resident's current therapeutic diet order of nothing by mouth (NPO), as required by facility policy. The resident was admitted with diagnoses including adult failure to thrive and Alzheimer's disease, and a physician's order was in place for NPO status due to the resident's inability to swallow food or medications. Despite this, a review of the resident's active care plans showed no documentation or care plan addressing the NPO order. Interviews with both a registered nurse and the Director of Nursing confirmed that the resident's NPO status was not included in the care plan, even though the resident was at high risk for aspiration if given food or fluids by mouth. The facility's policy required that a comprehensive, person-centered care plan, including physician and dietary orders, be developed and implemented within 48 hours of admission, but this was not done for the resident in question.
Failure to Protect Resident from Physical Abuse During Perineal Care
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) was observed by a resident's responsible party (RP) being rough during perineal care, causing the resident to experience pain and distress. The RP reported the incident to the facility's Infection Preventionist (IP) nurse, who then informed a licensed vocational nurse (LVN). Despite this report, the CNA continued to be assigned to the resident for the remainder of the shift and the following day. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was unable to effectively communicate her needs or discomfort due to a language barrier and her medical condition. The resident's care plan required staff to be gentle, explain procedures, and not rush care, but these interventions were not followed during the incident. On the following day, the RP again found the resident in distress, and the resident's roommate, who spoke the same language, reported hearing the resident screaming in pain while the CNA performed care. The CNA did not stop or seek assistance despite the resident's verbalizations of pain. The roommate expressed feeling scared and uncomfortable after witnessing the incident. Other staff members, including the LVN and registered nurse (RN), did not immediately recognize the rough care as potential abuse, did not report the incident to the abuse coordinator or administrator, and did not remove the CNA from caring for the resident until later in the day. Documentation and mandated reporting procedures were not followed at the time of the initial and subsequent complaints. The resident's medical history included traumatic subdural hemorrhage, type 2 diabetes, and major depressive disorder, with documentation indicating severe cognitive impairment and total dependence for mobility and personal care. The facility's policies required prompt reporting and investigation of abuse allegations, as well as protection of residents' rights and dignity. However, the failure to act on the initial and subsequent reports of rough care resulted in the resident being subjected to further distress and pain, and another resident experiencing fear and discomfort.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to notify the California Department of Public Health (CDPH), the Ombudsman, and Law Enforcement within two hours of an allegation of abuse, as required by both regulation and the facility's own policy. The allegation involved a certified nurse assistant (CNA) being rough during perineal care with a resident who was cognitively impaired and unable to make decisions. The responsible party (RP) observed the incident, reported it to the facility's Infection Preventionist (IP) nurse, and later to a registered nurse (RN), but the required notifications to authorities were not made until approximately 33 hours after the initial report. The CNA in question continued to be assigned to the resident after the allegation was reported, contrary to facility policy which requires immediate suspension of the accused staff member pending investigation. Documentation and interviews confirmed that the CNA provided care to the resident on both the day of the incident and the following day. The facility did not initiate an investigation or remove the CNA from resident care until after law enforcement was contacted by the RP and arrived at the facility. Multiple staff members, including the IP nurse, LVN, and RN, failed to recognize the incident as a reportable allegation of abuse and did not escalate or document the concern appropriately. The resident involved had a history of traumatic subdural hemorrhage, type 2 diabetes, and major depressive disorder, and was assessed as severely cognitively impaired and dependent for activities of daily living. The incident was witnessed by the RP and corroborated by the resident's roommate, who reported hearing the resident in distress and screaming during care. Despite these observations and the resident's inability to advocate for herself, the facility did not follow its own policies for reporting, investigation, and protection of the resident from further potential abuse.
Failure to Prevent and Investigate Abuse Leads to Resident Injury
Penalty
Summary
The facility failed to implement its policy and procedure to prevent, protect, report timely, and thoroughly investigate any allegation of abuse for a resident who reported rough handling by a certified nursing assistant (CNA) during activities of daily living. The resident, who had severe contractures and required careful handling, sustained an acute impacted fracture of the left upper arm, which was displaced, causing unbearable pain and discomfort, leading to hospitalization. The resident had a history of hypertension, weakness, polyarthritis, muscle wasting, and atrophy, and was admitted to the facility with these diagnoses. The resident's care plan indicated the need for careful handling to prevent trauma to the joints, but the CNA dismissed the resident's request for gentler care. The resident reported that the CNA was rough, ignored his pleas for gentleness, and handled him forcefully, causing significant pain. The resident's roommate corroborated the account, stating that the CNA handled the resident roughly and did not seek assistance from other staff. Despite the resident's complaints and visible injuries, the facility did not promptly report the abuse allegation or suspend the CNA involved. The Director of Nursing (DON) initiated an investigation but failed to interview the CNA or suspend him from work immediately. The facility's policy and procedure on abuse prevention and reporting were not followed, as the incident was not reported to the Department of Public Health in a timely manner, and the resident's allegation of abuse was not included in the Facility Reported Incident. The facility's failure to adhere to its policies resulted in the resident's injury and subsequent hospitalization.
Failure in Discharge Planning and Coordination
Penalty
Summary
The facility failed to provide appropriate discharge planning and assistance for a resident's safe discharge by not ensuring that home health services and durable medical equipment (DME) were arranged and confirmed for delivery prior to the resident's discharge. The resident, who had diagnoses including Parkinson's Disease, Dementia, and Difficulty in Walking, required substantial assistance with daily activities and was supposed to be discharged with home health services for physical and occupational therapy, medication management, and specific DME including a front-wheeled walker and a compact wheelchair. Interviews revealed a lack of coordination and communication among the facility's staff. The Social Service Director discussed discharge planning with the family but was not responsible for arranging home health services. The Case Manager, who was responsible for coordinating with the insurance company for authorizations, did not request or follow up on the necessary services and equipment. The Administrator confirmed that both the Social Service and Case Manager were responsible for ensuring discharge readiness and arrangements. As a result, the resident did not receive the required rehabilitation therapy or DME after being discharged home.
Failure to Complete and Document CNA Competency Assessments
Penalty
Summary
The facility failed to provide evidence that the Annual Certified Nurse Assistant (CNA) Core Clinical Competencies (ACCC) were completed for eight sampled CNAs. The Director of Nursing (DON) acknowledged that there was no system in place to track the CNAs' performance evaluations, which should have included a spreadsheet listing all active CNAs with their hire dates and last ACCC dates. Interviews with CNAs revealed that they could not recall when their last annual skill competencies were evaluated, indicating a lack of consistent assessment and training. During a review of the CNAs' employee files, no ACCC documentation was found for the sampled CNAs. The DON confirmed that only partial evidence of skills competencies, such as showering/bathing and donning and doffing gloves, was available, which did not account for the complete annual skills checks required. The facility's policy stated that competency assessments should be retained in employee files, but this was not adhered to, leading to a deficiency in ensuring CNAs' skills and competencies were up to date.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide the name and indication of medications to a resident before administration, affecting one of the seven residents observed for medication administration. During an observation, a Licensed Vocational Nurse (LVN) administered 11 medications, including two docusate sodium tablets, to a resident without informing them of the medication names and their purposes. The resident expressed a preference not to receive laxatives that morning, but the LVN had already administered the docusate tablets. The LVN acknowledged forgetting to inform the resident, which is a violation of the resident's rights to be informed and make decisions about their medication regimen. Additionally, the facility failed to account for six doses of controlled substances for four residents, leading to discrepancies in the medication accountability records. During an inspection of a medication cart, it was found that doses of oxycodone with acetaminophen, Lacosamide, lorazepam, and clonazepam were missing from the medication bubble packs compared to the counts on the Individual Narcotic Record accountability logs. The LVN admitted to administering these medications but failed to document the administrations on the accountability logs, which is against the facility's policy. The Director of Nursing confirmed that the LVN should have informed the resident of the medication details and that the failure to document controlled substance administrations could lead to potential medication errors and diversion. The facility's policies require immediate documentation of controlled substance administrations to ensure accountability and prevent errors. The failure to adhere to these policies resulted in a violation of resident rights and increased the risk of medication errors.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 5.71% due to two medication errors out of twenty-four opportunities. These errors affected two residents during medication administration. One resident received a different form of calcium than what was prescribed by their physician, while another resident received a multivitamin with minerals instead of the prescribed multivitamin without minerals. During observations, it was noted that a Licensed Vocational Nurse (LVN) administered the incorrect multivitamin to a resident, and another LVN administered calcium with Vitamin D instead of the prescribed calcium without Vitamin D. These actions were confirmed through interviews with the LVNs, who acknowledged the errors and recognized them as medication errors. The Director of Nursing also confirmed that the medications were not administered as ordered by the physicians. The residents involved had specific medical conditions that required precise medication management. One resident had a history of kidney disease and was prescribed calcium for hypocalcemia, while the other resident had hypomagnesemia and was prescribed a multivitamin. The facility's policies and procedures for medication administration emphasize the importance of administering medications as prescribed, but these were not followed in these instances, leading to the medication errors.
Expired Medications Not Removed from Stock
Penalty
Summary
The facility failed to properly manage and dispose of expired medications in one of its medication rooms, specifically Medication Room Station 1 South West. During an observation, an open vial of Aplisol, used for tuberculosis diagnosis, was found in the refrigerator without a label indicating when it was opened, contrary to the manufacturer's guidelines which require it to be used or discarded within 30 days of opening. Additionally, 15 prefilled syringes of the Afluria influenza vaccine, which expired on June 30, 2024, were found stored in the refrigerator. These medications were not removed from stock as required by the facility's policies. Interviews with the LVN and the DON revealed that the lack of labeling on the Aplisol vial made it impossible to determine its expiration, and the expired Afluria syringes should have been discarded to prevent accidental use. The facility's policies stipulate that expired medications should be immediately removed from stock and stored in a designated area for disposal. The failure to adhere to these policies increased the risk of administering ineffective or potentially harmful medications to residents.
Inadequate Training of Kitchen Staff on Sanitizer Use
Penalty
Summary
The facility failed to ensure that a kitchen staff member, identified as Dishwasher 1 (DW 1), was routinely trained and evaluated for competency in their duties. During an observation, DW 1 was found using a chlorine sanitizer test strip in a quaternary ammonium (QUAT) sanitizer solution, which is incorrect. The test strip did not change color, indicating a lack of understanding of the proper procedure. The Dietary Supervisor (DS) intervened, providing the correct test strip and instructing DW 1 on the proper method, which involves immersing the strip for 10 seconds. Initially, DW 1 dipped the strip for only one second, resulting in no color change. Upon following the correct procedure, the sanitizer was found to be at an acceptable concentration of 200 parts per million (PPM). Further investigation revealed that the facility's in-service training did not include instructions on testing sanitizer solutions, and the dishwasher's job description emphasized maintaining a safe and sanitary environment. The Registered Dietitian (RD) confirmed that the QUAT solution should be at least 200 PPM and noted a recent change in the test strip product, which may have contributed to the confusion. The manufacturer's instructions for the QUAT sanitizer test strips clearly stated the need for a 10-second immersion to obtain an accurate reading, highlighting a gap in staff training and competency evaluation.
Deficiency in Adhering to Prescribed Portion Sizes
Penalty
Summary
The facility failed to adhere to the prescribed portion sizes for residents on pureed and mechanical soft diets during the lunch service on 7/9/2024. Specifically, 12 residents on a pureed diet received 4 ounces of chicken oregano instead of the required 5 and 1/3 ounces, and 46 residents on a mechanical soft diet received 2 and 2/3 ounces of zucchini instead of the prescribed 4 ounces. This discrepancy was observed during the tray line service, where the cooks used incorrect scoop sizes, leading to the serving of smaller portions than indicated in the facility's food portion and serving guide. Interviews with the cooks revealed that they mistakenly used smaller scoops, resulting in the under-serving of chicken and zucchini. The Registered Dietician (RD) confirmed the error and emphasized the importance of following the menu and spreadsheet to ensure residents receive the correct portions to meet their nutritional needs. The facility's policy and procedure on menus, revised in 2014, mandates adherence to the written menu to meet the nutritional requirements set by the food and nutrition board of the national research council.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote dignity and respect for two residents during meal assistance. Certified Nursing Assistants (CNAs) were observed standing over the residents while feeding them breakfast, which violated the residents' rights to dignity and respect. Resident 16, who was severely cognitively impaired and required substantial assistance with eating, was fed by CNA 1 while lying in bed with the head elevated. Similarly, Resident 80, who also had severe cognitive impairment and required moderate assistance with eating, was fed by CNA 3 in the same manner. Both CNAs acknowledged that they should have been at eye level with the residents to maintain their dignity. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nurses (DON), confirmed that the CNAs should have been seated at eye level with the residents during feeding to uphold their dignity. The facility's policy on resident rights emphasizes care that promotes dignity and prohibits demeaning practices. The observations and interviews indicate a failure to adhere to these standards, compromising the residents' dignity during meal times.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, as required by the facility's policy and procedure. Resident 357, who has major depression, aphasia, and Parkinsonism, was observed with the call light tied to the right bedrail, out of reach. Despite the care plan indicating the need for the call light to be within easy reach, the resident was unable to use it to call for assistance. The Director of Nursing acknowledged the importance of having the call light accessible to the resident. Similarly, Resident 26, who has Parkinsonism, hypertensive heart disease, diabetes, and right hemiparesis, was found with the call light attached to the right upper corner of the bed, inaccessible to the resident's functional left hand. The care plan for Resident 26 also required the call light to be within easy reach, especially given the resident's fall risk and communication deficit. The Licensed Vocational Nurse and Occupational Therapist both confirmed that the call light should be accessible to the resident's left hand. The facility's policy, dated 1/1/2012, mandates that call cords be placed within the resident's reach to enable them to alert nursing staff. The failure to adhere to this policy for both residents was confirmed through observations and interviews with staff, including the Director of Nursing, who emphasized the necessity of having the call light within reach to accommodate residents' needs and ensure their safety.
Failure to Report Change in Condition for Resident's Eye Redness
Penalty
Summary
The facility failed to report a significant change in condition for a resident, identified as Resident 48, who exhibited redness in both eyes. This deficiency was identified through observation, interview, and record review. Resident 48, who has a medical history including hypertension, obesity, type 2 diabetes mellitus with diabetic nephropathy, and bilateral age-related cataract, was observed with reddened eyes. Despite the redness being noted by staff, it was not reported to the attending physician in a timely manner, resulting in a delay in receiving necessary care and treatment. On the morning of the incident, Resident 48 was observed with redness in the sclera of both eyes and reported that the redness had been present since the previous morning. The resident expressed discomfort and a need for eye drops, which had not been administered. Licensed Vocational Nurse (LVN) 6 acknowledged noticing the redness for two to three days but did not report it, assuming it had already been documented. LVN 3, responsible for the resident's care on the day shift, did not assess the eyes, as assessments were scheduled weekly, and no report was received from the Certified Nurse Assistant (CNA). Interviews with the Director of Nurses (DON) and Registered Nurse (RN) 2 confirmed that the redness should have been reported to the physician for monitoring and potential intervention. The facility's policy on Change in Condition Notification requires notifying the attending physician of any sudden and marked adverse change in a resident's condition. However, this protocol was not followed, leading to a delay in addressing the resident's eye condition.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident during personal care. A certified nurse assistant (CNA) was observed cleaning a resident without clothes in their room without pulling the privacy curtain, leaving the resident exposed. This incident occurred while the resident's roommate was present, further compromising the resident's privacy. The CNA admitted to forgetting to pull the curtain, which is a necessary step to ensure privacy during such procedures. The resident involved had severe cognitive impairment and required substantial assistance with personal hygiene. The facility's policy mandates that privacy must be provided to all residents, including those who are cognitively impaired, to preserve their dignity. Interviews with the registered nurse and the director of nurses confirmed that the privacy curtain should have been used to prevent exposure and maintain the resident's dignity, as outlined in the facility's policy on resident rights and quality of life.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to potential inadequate care. Resident 48, who was readmitted with multiple diagnoses including hypertension, obesity, type 2 diabetes with diabetic nephropathy, and bilateral cataracts, was observed with redness in both eyes. Despite having physician orders for eye health and artificial tears, there was no care plan addressing the intervention for the eye redness. The lack of a care plan was confirmed by RN 2 and the Director of Nurses (DON), who acknowledged the importance of a care plan to communicate necessary interventions and monitor the resident's condition. Similarly, Resident 99, admitted with an inguinal hernia and weight loss, did not have a care plan for the management of the hernia. The resident, who had intact cognition, reported abdominal discomfort affecting his eating. RN 1 confirmed the absence of a care plan for the hernia, and the DON stated that a care plan should have been in place. The facility's policy requires care plans to be updated with new problems or changes in condition, which was not adhered to in these cases.
Failure to Update Care Plan for Resident's Incontinence Post-Catheter Removal
Penalty
Summary
The facility failed to review and revise a resident-centered care plan for a resident, identified as Resident 93, who experienced occasional bladder incontinence following the removal of a urinary catheter. The comprehensive care plan, initially developed upon admission and revised months later, did not address the resident's incontinence after the catheter was removed. This oversight resulted in inconsistent care and services for the resident, who was at risk of urinary tract infections. Resident 93 was admitted with diagnoses including dementia and psychosis, and had a urinary catheter due to urinary retention. The care plan aimed to prevent urinary infections and trauma related to catheter use. However, after the catheter was removed, the care plan was not updated to reflect the resident's incontinence. Interviews with facility staff, including a registered nurse and the Director of Nurses, confirmed that the care plan should have been revised to include interventions for the resident's incontinence, but this was not done.
Failure to Set LAL Mattress Correctly for Resident
Penalty
Summary
The facility failed to implement appropriate care and services to prevent the development of pressure ulcers for a resident, identified as Resident 15, by not ensuring the Low Air Loss (LAL) mattress was set according to the physician's order. The physician had ordered the LAL mattress to be set at a level suitable for a body weight of 275 pounds, but it was observed to be set at a level for 150 pounds, which was too soft for the resident's actual weight of 281 pounds. This discrepancy was noted during observations and interviews with facility staff, including a Certified Nursing Assistant and the Director of Staff Development, who acknowledged the incorrect setting. Resident 15 had a history of morbid obesity and hemiplegia following a cerebral infarction, with severely impaired cognitive skills requiring substantial assistance for daily activities. The facility's policy required that air mattresses be set according to the resident's weight and checked routinely to ensure proper functioning. However, the LAL mattress was not set correctly, potentially putting the resident at risk for skin breakdown. The Director of Nursing confirmed the physician's order and the resident's weight, acknowledging that the mattress setting was incorrect and could lead to discomfort and failure to prevent skin breakdown.
Failure to Secure Indwelling Catheter and Maintain Hygiene Standards
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, which is a flexible tube inserted into the bladder for continuous urinary drainage. The deficiency was identified when the catheter was observed to be unsecured and the catheter bag was touching the floor. This was noted during an observation and interview with an LVN, who acknowledged that the urinary bag should not be in contact with the floor, even if the bed is in a low position. Another LVN confirmed that the catheter tubing should be anchored to the resident's leg to prevent pulling or dislodgement. The Director of Nurses (DON) was interviewed and acknowledged the issue, stating that they had spoken to the RNs about securing the catheter and ensuring the urinary bag is kept off the floor. The facility's policy on catheter care, dated June 10, 2021, specifies that the catheter should be anchored to prevent excessive tension and that the catheter tubing, bag, or spigot should not touch the floor. This failure to adhere to the policy placed the resident at risk for potential accidental dislodgement of the catheter and urinary tract infection.
Deficient Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide proper oxygen therapy and necessary respiratory care services for two residents, Resident 31 and Resident 50. For Resident 31, who was using a nasal cannula for continuous oxygen therapy, the device was improperly placed on the resident's right cheek instead of the nostrils. This was observed during a general observation and confirmed by a Licensed Vocational Nurse (LVN) who noted the nasal cannula was not correctly positioned. The Director of Nursing (DON) acknowledged that the nasal cannula should have been properly placed to ensure effective oxygen treatment as ordered by the physician. For Resident 50, the facility failed to label the nasal cannula with the date of the last change, as required by the physician's order. Additionally, Resident 50 was observed receiving oxygen at 4 liters per minute (LPM) instead of the prescribed 2 LPM. The lack of proper labeling and incorrect oxygen flow rate were confirmed by LVN 3 and the DON. Furthermore, Resident 50's oxygen saturation and respiratory rate were not documented on the day of observation, and the resident was found without oxygen for 15 minutes during assistance with activities of daily living (ADL), which led to fluctuating oxygen saturation levels. The facility's policy and procedure for oxygen therapy, issued in November 2017, indicated that oxygen should be administered per physician orders under safe and sanitary conditions. However, the observations and interviews revealed that the facility did not adhere to these procedures, resulting in deficiencies in the respiratory care provided to Residents 31 and 50.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 65, who was observed experiencing pain without being assessed or reassessed according to the facility's policy. Resident 65, who has a history of arthritis, muscle wasting, osteoarthritis, and dementia, was admitted with a physician's order to assess pain every shift and administer Methocarbamol for knee and leg pain. However, on the evening shift of 7/9/2024, there was no documented evidence of a pain assessment, and the resident was observed in distress, calling for help and holding her knees. During an interview, Resident 65 reported severe pain, rated 10/10, but the Licensed Vocational Nurse (LVN) in charge did not administer pain medication early due to concerns about the resident's psychiatric medication schedule. The LVN did not assess the resident's pain or reassess after administering the scheduled pain medication. The Registered Nurse (RN) and Director of Nurses (DON) later confirmed that the LVN should have assessed and documented the resident's pain and attempted non-pharmacologic interventions before administering medication. The facility's policy requires licensed nurses to assess pain upon admission, quarterly, and when there is a new onset or exacerbation of pain. It also mandates reassessment within one hour after administering pain medication. The failure to follow these procedures resulted in delayed care for Resident 65, potentially affecting her well-being and healing process.
Failure to Follow Up on Resident's Surgery Plan
Penalty
Summary
The facility failed to provide medically-related social services for a resident diagnosed with an inguinal hernia, which led to a deficiency in care. The resident, who was admitted with a history of inguinal hernia and weight loss, expressed a desire to proceed with surgery. Despite having intact cognition and the capacity to make medical decisions, the facility did not follow up on the resident's surgery plan. The resident's medical records indicated a pending surgery consult and a need for clearance from oncology, but there was no documented evidence of the facility's attempts to contact the physician or follow up on the surgery after an initial note on 4/17/2024. Observations and interviews revealed that the resident experienced abdominal discomfort, affecting their ability to eat, and repeatedly expressed a desire for surgery. Staff, including RNs and the DON, acknowledged the resident's wish for surgery but cited the need for oncologist clearance as a barrier. The facility's policies on referrals and resident rights emphasize the coordination of outside services and honoring residents' medical choices, but these were not effectively implemented in this case, resulting in the resident's medical choice not being honored and potential discomfort due to the delay in surgery.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection control program effectively, as evidenced by several deficiencies observed during a survey. In one instance, a shared restroom for Room A, which accommodates six residents, was found to have an unlabeled urinal and three rectangle wash basins placed on top of the toilet reservoir tank. A Certified Nursing Assistant (CNA) admitted to using the urinal for emptying a resident's urinary catheter drainage bag without knowing the ownership of the wash basins. The Infection Prevention Nurse (IPN) and the Director of Nurses (DON) acknowledged the importance of labeling and dating urinals and wash basins to prevent cross-contamination, although the facility lacked a specific policy for this practice. Additionally, the facility failed to ensure that urinals at the bedside tables of two residents were labeled with their names and the date of first use. Both residents had moderately impaired cognitive status and required assistance with daily activities. During an observation, a CNA noted the presence of unlabeled urinals with urine at the bedside tables of these residents, acknowledging that they should have been emptied, labeled, and dated to prevent infection. Interviews with nursing staff confirmed that unlabeled urinals could lead to bacterial growth and cross-contamination, posing an infection control issue. Furthermore, the facility did not ensure that staff used appropriate protective equipment when providing care to a resident with a foot wound. A CNA was observed assisting the resident without wearing an isolation gown, despite the resident's risk of infection due to a diabetic foot ulcer. The IPN confirmed that enhanced barrier precautions, including the use of gowns and gloves, should be employed during high-contact care activities for residents with wounds. However, the facility did not have a system to input enhanced barrier precaution orders in residents' medical records, leading to a lack of adherence to infection control protocols.
Non-Functioning Call Light in Resident's Bathroom
Penalty
Summary
The facility failed to provide a functioning call light in the shared bathroom of a resident, identified as Resident 357. This deficiency was discovered during an observation and interview with the resident, who was found to be awake, alert, and able to respond to questions. The resident, who has diagnoses including major depression, aphasia, and Parkinsonism, and requires substantial assistance with activities of daily living, was unaware that the call light was not working. The resident expressed that having a working call light in the bathroom is important for safety in case assistance is needed. Further investigation revealed that the Director of Staff Development confirmed the non-functioning call light and emphasized its importance for resident safety. The Maintenance Staff (MS) stated that monthly checks are conducted on call lights, but no reports of defective call lights were made this month. The facility's policy requires that defective call lights be reported and replaced immediately, highlighting a lapse in adherence to this policy. The last entry in the facility's Nurse Call System logbook was dated prior to the observation, indicating a potential gap in monitoring and maintenance.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This deficiency was identified during an observation and interview with the Director of Nurses (DON) and the Administrator (ADM). The DON stated that the Director of Staff Development (DSD) was responsible for updating and posting the staffing information daily in a designated area. However, during an observation, it was found that the staffing information posted was dated the previous day. The ADM admitted that although the DSD had updated the staffing information and left a printout in the DSD's office, the ADM forgot to post it. According to the facility's policy, the staffing data should be updated and posted at the beginning of each shift, before 6 AM, to ensure accessibility to all residents and visitors.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with federal regulations regarding the maximum number of residents per room, as observed during a recertification survey. Specifically, eight out of 41 rooms were found to accommodate more than the allowed four residents per room. Rooms 2, 19, 23, 26, and 39 each had five beds, while other rooms had six beds, with varying numbers of residents occupying them. This arrangement potentially compromised the residents' privacy and the quality of care and safety due to inadequate space for nursing care and emergency services. During the survey, the facility's Administrator acknowledged the situation, stating that the facility had room waivers approved by the Centers for Medicare & Medicaid Services for rooms that did not meet the regulation requirements. Despite the waivers, the surveyors noted that the rooms did not meet the federal requirement of no more than four beds per resident room. However, during a resident council interview, no concerns were raised by the residents regarding room sizes. The facility's room waiver letter indicated that the rooms had adequate space for nursing care and that multiple beds per room would not adversely affect the residents' health and safety.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that resident care areas in multiple resident bedrooms met the required 80 square feet per resident, as mandated by regulations. This deficiency was identified in 18 out of 41 resident rooms during a recertification survey. The facility's administrator acknowledged the issue and stated that the facility had room waivers approved by the Centers for Medicare & Medicaid Services for rooms that did not meet the regulation requirements. The facility planned to continue applying for these waivers. The Client Accommodation Analysis submitted by the facility indicated that several rooms did not meet the required square footage per resident, with some rooms having as little as 51.1 square feet allocated per resident. Despite the deficiency, observations during the survey indicated that the size of the rooms did not interfere with the care and services provided by the staff. Residents were observed to have adequate space for their beds, dressers, and care equipment. Additionally, during a group interview with the resident council, no concerns were raised regarding room sizes. The facility's waiver request letter stated that the arrangement of the rooms provided adequate space for nursing care and did not adversely affect the health and safety of the residents.
Failure to Honor Resident Preferences and Dignity
Penalty
Summary
The facility failed to treat two residents with respect and dignity by not honoring their preferences and choices regarding activities of daily living (ADL). Resident 2, who was admitted with a diagnosis of depressive disorder and adult failure to thrive, required partial to moderate assistance with personal hygiene. Despite care plans indicating that staff should not rush the resident and should explain all necessary procedures, Resident 2 experienced a fall during care when two CNAs forcibly changed her diaper against her will. This incident led to Resident 2 sustaining a bump on her head and being sent to the hospital for further evaluation. Resident 2 reported feeling upset and dehumanized by the experience, stating that the CNAs held her down and ignored her pleas to stop, which ultimately led to her fall while trying to retrieve her personal belongings from the floor using a grabber tool. Resident 3, who was admitted with a diagnosis of heart disease and muscle weakness, also experienced a lack of respect and dignity in her care. Despite a care plan that emphasized not rushing the resident and allowing her to complete tasks at her own pace, an unnamed CNA entered her room early in the morning, removed her covers, and forcibly changed her diaper without her consent. Resident 3 reported that the CNA's actions caused her physical pain and distress, as the CNA did not honor her requests to stop. This behavior was corroborated by an LVN who stated that residents have the right to refuse care and that their wishes must be honored. The facility's policy and procedure on resident rights, which was revised in 2012, indicated that staff should provide all residents with kindness, respect, and dignity, and honor their exercise of rights. The policy also emphasized encouraging residents to participate in planning their daily care routines, including ADLs. However, the actions of the CNAs in both cases directly contradicted these guidelines, leading to the deficiencies observed by the surveyors.
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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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