Mountain Manor Senior Residence
Inspection history, citations, penalties and survey trends for this long-term care facility in Carmichael, California.
- Location
- 6101 Fair Oaks Boulevard, Carmichael, California 95608
- CMS Provider Number
- 555889
- Inspections on file
- 25
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Mountain Manor Senior Residence during CMS and state inspections, most recent first.
A resident re-admitted with hypovolemic shock and muscle weakness, and with intact cognition per BIMS, had a hospital order for metoprolol 100 mg BID. When the order was transcribed into the facility’s EMR, an LPN incorrectly entered the dose as 200 mg BID, and the MAR reflected this error, documenting administration of a 200 mg dose. The NP later confirmed the correct dose should have been 100 mg BID and noted that an incorrect dose could worsen low BP and cause dizziness or a fall, while the DON confirmed the transcription error, which was inconsistent with facility policies requiring accurate documentation and medication administration per prescriber orders.
A resident with acute respiratory failure and hydration issues did not receive IV therapy in accordance with professional standards, as the physician's order for a one-time IV bolus lacked clarification on infusion duration, and LNs failed to document key aspects of IV therapy, including insertion details, site assessments, pharmacy communication, and administration times. These deficiencies were confirmed by the DON and were not in line with facility policy or nursing regulations.
A resident with severe cognitive impairment and a history of wandering was not consistently monitored for proper placement and functionality of their alarm bracelet, as required by physician orders and facility policy. Documentation in the MAR and TAR did not show that checks were performed every shift or daily, and staff confirmed the lack of monitoring and documentation.
A resident with diabetes received rapid-acting insulin before eating, contrary to the physician's order to administer the medication with meals. Both the nurse and the resident confirmed the insulin was given prior to the meal, and facility policy requires medications to be administered as ordered, particularly regarding timing with meals.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with dementia, depression, and anxiety was prescribed trazodone for insomnia, but the care plan did not address sleep issues or the new medication. Both a nurse and the DON confirmed the absence of a care plan for insomnia, despite facility policy requiring comprehensive care plans for all identified needs.
A resident with vascular dementia developed a bruise on the right cheek, and although a physician ordered monitoring every shift, the care plan was not updated to reflect this change in condition. Staff interviews and record reviews confirmed that the care plan lacked necessary revisions and did not include the new monitoring interventions as required by facility policy.
Surveyors identified multiple failures in food safety and sanitation, including an unclean ice machine, damaged kitchen equipment, improper food labeling and storage, spoiled produce, and inadequate monitoring and cleaning of the resident food refrigerator and freezer. These deficiencies were confirmed by dietary and maintenance staff and were not in accordance with facility policies or professional standards.
The facility did not ensure accurate documentation and accountability of controlled substances, including missing entries on the MAR for two residents who received hydrocodone/APAP, incomplete shift-to-shift controlled drug count records due to missing nurse signatures, and incomplete documentation of narcotic removal from the emergency kit. These failures were confirmed by staff and were not in accordance with facility policies.
Surveyors found that multi-dose medications were not labeled with open or discard dates, prescription medications lacked pharmacy labels to identify the intended resident, and expired drugs were present in storage. Medications with different administration routes were stored together, and loose pills were not properly disposed of. Staff interviews confirmed these practices were inconsistent with facility policy and manufacturer instructions.
Two dietary aides were unable to accurately describe or perform the correct manual dishwashing procedures, including proper wash, rinse, sanitize steps, water temperatures, and sanitizer immersion times, despite having been marked as competent and trained. This failure had the potential to affect all residents receiving food from the kitchen due to improper sanitation of dishware.
The facility did not adhere to prescribed therapeutic diet menus and portion sizes, resulting in residents on CCHO diets receiving incorrect desserts, residents on fortified diets not receiving required fortified foods, and residents on large portion diets being served less protein than specified. These failures were confirmed by dietary staff and were not in accordance with the facility's menu spreadsheets and diet manual.
The facility did not implement Enhanced Barrier Precautions for several residents with wounds, indwelling medical devices, or infections, as required by policy, and failed to provide appropriate signage and PPE. Additionally, a CNA was observed distributing meal trays to multiple residents without performing hand hygiene between each, contrary to facility protocols.
Four residents experienced ongoing discomfort and sleep disruption due to excessive noise from staff and hallway activity, including yelling and loud conversations, with some residents resorting to using blankets or privacy curtains to reduce the impact. Despite complaints and a facility policy emphasizing comfortable noise levels, staff actions and inactions led to a persistently noisy environment.
A resident with dementia, depression, and anxiety was prescribed trazodone for insomnia, but staff and the DON confirmed that no care plan was developed to address the resident's sleep issues or trazodone use, contrary to facility policy requiring comprehensive, measurable care plans.
A resident with vascular dementia developed a bruise on the right cheek, which was documented and monitored per physician order, but the care plan was not updated to reflect this change in condition. Both nursing staff and the DON confirmed the care plan should have been revised according to facility policy.
A nurse administered calcium carbonate to a resident without clarifying an unclear physician's order regarding the correct dosage. The nurse gave one 500 mg tablet, though the order referenced 1250 mg, and later acknowledged the need for clarification. The DON confirmed that staff are expected to clarify unclear orders, in accordance with facility policy.
A resident with chronic respiratory failure and a language barrier was care planned to use a communication board for effective communication. Despite this, staff were unable to locate or use the communication board during care, making communication difficult and not following the resident's care plan.
A resident with an order for oxygen at 2 L/min via nasal cannula as needed for shortness of breath was observed receiving only 1 L/min, despite still experiencing symptoms. This was confirmed by a nurse, and the DON stated that staff are expected to follow physician orders accurately.
The QAA committee did not include the Medical Director as a required member during a quarterly QAPI meeting, as confirmed by review of meeting records and facility policy.
A resident was prescribed and administered levofloxacin for a UTI despite having no symptoms and only asymptomatic bacteriuria on lab results. The antibiotic was started based solely on a hospital urinalysis, without clinical justification, contrary to the facility's Antibiotic Stewardship policy.
A resident with congestive heart failure was transferred to the hospital multiple times without being provided the required written bed hold notification. Documentation was incomplete or missing for each transfer, with no evidence that the bed hold policy was communicated or acknowledged as required by regulation.
A resident with cognitive impairment and a history of falls eloped from the facility unaccompanied, resulting in a fall and complaints of pain. The resident, assessed as a moderate risk for wandering, left during a time when staff were attending to another resident. The facility's elopement policy lacked specific preventive interventions.
A resident with heart problems was moved to a new room without advance notice or consent, violating their rights. The facility's policy requires prior notification and consent, but no documentation was found in the resident's medical record. The move was discussed in a morning meeting, but the resident was informed abruptly and left confused about the change.
The facility failed to maintain food safety standards, with issues including an unclean ice machine, spoiled tomatoes in storage, improperly stored metal pans, staff personal items in food storage, and a dusty juice dispenser. The CDM and RD acknowledged these deficiencies, which were against facility policies.
The facility did not replace two opened emergency drug kits in the medication room, as required by policy. E-kit #53, containing controlled medications, and e-kit #49, containing oral medications, were accessed multiple times but not replaced by the pharmacy. The ADON confirmed that staff should have ensured replacement with the next delivery, as the pharmacy delivers twice daily.
Two residents experienced medication errors, leading to a facility error rate of 5.41%. One resident received an incorrect dose of famotidine, while another did not receive their prescribed metoprolol succinate due to a pharmacy delivery issue. The facility's policies for medication administration were not followed, resulting in these errors.
A survey found multiple deficiencies in medication storage and labeling at a facility. Six inhalers lacked open dates, two insulin vials were expired, and expired glucometer solutions were found, risking inaccurate readings. Blister packs were misplaced, and loose pills were discovered in a medication cart. The ADON acknowledged these issues, confirming the need for proper labeling and storage.
The facility did not follow the therapeutic diet menu during a lunch service, affecting five residents. Residents on a CCHO diet received a full serving of dessert instead of half, and a resident on a mechanical soft diet was served a salad with croutons, contrary to dietary guidelines. The CDM and RD acknowledged these errors, which were not in line with the facility's dietary policies.
The facility failed to complete the MDS Admission Assessment within the required 14 days for two residents. One resident with dementia had their assessment completed 28 days after admission, while another with altered mental status had theirs completed 26 days post-admission. The DON acknowledged the late submissions, which did not comply with the facility's policy.
A facility failed to create a comprehensive care plan for a resident with end-stage renal disease who required dialysis. Despite the resident's admission records indicating dependence on dialysis and scheduled treatments, there was no care plan addressing her dialysis needs. Staff confirmed the absence of a care plan, which is required by the facility's policy to meet residents' needs.
A resident with a tibial plateau fracture was observed wearing a leg/knee immobilizer without a physician's order. The PT confirmed the need for the immobilizer, but the order was missing from the records. The ADON admitted forgetting to document the order after hospital clarification, violating the facility's policy on recording verbal orders.
A resident with dementia had long, dirty fingernails, which were not addressed by the facility staff. The CNAs noticed the issue but failed to inform the Licensed Nurse or Activities Aide, and no nail care plan was initiated despite the resident's self-care deficiency. The facility's policy on daily nail cleaning was not followed, increasing the risk of infection.
A resident with muscle weakness and physical debility did not receive the prescribed treatment to float her heels while in bed, as observed during a facility survey. Despite an active order to prevent skin breakdown, the resident's feet were not floated, and this was confirmed by a licensed nurse. The ADON emphasized the expectation for staff to follow physician orders and document any refusals.
A resident with cataracts and syncope was not provided with necessary prescription eyeglasses, despite documented need in her assessment. Staff interviews confirmed the oversight, with the Social Worker failing to facilitate referrals for the eyeglasses. The facility's policy requires social services to coordinate such referrals based on resident needs.
The facility failed to ensure two residents were free from unnecessary medications. A resident was prescribed an anti-anxiety medication without a stop date, despite a recommendation to include one. Another resident was given an antibiotic for recurring UTIs without a specified duration, even though the last UTI was documented two years prior. Both cases violated the facility's policies on medication orders.
A CNA in a COVID-19 unit failed to wear a face shield or goggles while assisting a COVID-19 positive resident, despite facility policy and visible signage requiring such PPE. The CNA wore an N-95 mask, gown, and gloves, but did not fully comply with the infection control protocols. Interviews with staff confirmed the PPE requirements, and the facility's policy outlined the necessity of these measures.
The facility did not post daily staffing information at the beginning of each shift for a census of 38 residents. Staffing details were not posted over the weekend and were delayed during weekdays, contrary to the facility's policy requiring posting within two hours of the day shift start. This was confirmed by the Staffing Coordinator and Assistant Director of Nursing.
Several residents on therapeutic diets did not receive the correct menu items or portion sizes as prescribed, including those on CCHO and fortified diets who were served incorrect desserts or missed fortified foods, and others who received less protein than required. These failures were confirmed by dietary staff and had the potential to compromise nutritional status.
Medication Transcription Error Leads to Incorrect Metoprolol Dose
Penalty
Summary
The facility failed to ensure that metoprolol was administered according to physician orders for one resident. The resident was re-admitted in February 2026 with hypovolemic shock and muscle weakness, and had an MDS BIMS score of 13/15, indicating intact cognitive function. Hospital physician orders dated 2/18/26 directed that the resident was to receive metoprolol 100 mg twice daily. However, when the orders were transcribed into the facility’s electronic medical record on 2/18/26, the metoprolol dose was incorrectly entered as 200 mg to be given twice daily. The resident’s MAR for 2/18/26 reflected the incorrect order, stating “Metoprolol 100 mg, give 200 mg two times a day,” and documented that one 200 mg dose was administered on 2/19/26 at 8 a.m. An LPN confirmed administering the 200 mg dose, and another LPN acknowledged making a medication error during transcription of the hospital physician orders by entering 200 mg instead of 100 mg twice daily. The NP stated the resident was supposed to receive 100 mg twice daily and that an incorrect dose could further exacerbate the resident’s low blood pressure and lead to dizziness or a fall. The DON confirmed that the metoprolol order had been transcribed incorrectly and stated that nursing staff should enter physician orders as written. Facility policies required that documentation in the medical record be complete and accurate and that medications be administered in accordance with prescriber orders.
Failure to Clarify and Document IV Therapy Orders and Administration
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice for a resident who had acute respiratory failure with hypoxia and hydration problems due to nausea and vomiting. Specifically, the physician's order for a one-time IV bolus was not clarified to specify the infusion duration, and licensed nurses did not thoroughly document all aspects of the IV therapy. This included missing documentation of the date and time of IV insertion, the IV catheter gauge, IV site assessment results, and the resident's response to the therapy. Additionally, the licensed nurses did not document when the physician's order was faxed to the pharmacy or whether the pharmacy received the order, which was necessary to ensure timely delivery of IV supplies. There was also a lack of documentation regarding the start and end times of the IV bags administered, including the IV bolus. These documentation gaps were confirmed during interviews and record reviews with the Director of Nursing, who acknowledged that the orders should have been clarified and that all aspects of IV therapy should have been properly recorded. A review of the facility's policy and procedure for IV therapy staff responsibilities indicated that verification and clarification of physician orders, notification of pharmacy, and documentation of all aspects of IV therapy are required. The Nursing Practice Act Rules and Regulations also outline the responsibilities of nursing staff in administering medications and therapeutic agents as ordered by a physician. The failure to follow these standards resulted in incomplete documentation and unclear communication regarding the resident's IV therapy.
Failure to Monitor and Document Alarm Bracelet Checks for High-Risk Resident
Penalty
Summary
A resident with Alzheimer's disease, dementia, and major depressive disorder, who was assessed as high risk for wandering and elopement, was observed wearing an alarm bracelet intended to alert staff if the resident attempted to leave the facility unattended. The resident's care plan and physician's orders required that the alarm bracelet be checked for placement every shift and for functionality every day shift. However, a review of the Medication Administration Record (MAR) and treatment administration records (TAR) for the relevant month showed no documentation that these checks were being performed as ordered. Interviews with facility staff, including a licensed nurse and the Director of Staff Development, confirmed that there was no evidence the alarm bracelet was being monitored for placement or functionality as required. Both staff members acknowledged the importance of these checks to ensure the device was working properly. The facility's policy on safety and supervision also required that interventions to reduce accident risks, such as monitoring safety devices, be implemented correctly and consistently. The lack of documentation and monitoring represented a failure to follow professional standards of practice, facility policy, and physician orders.
Insulin Administered Prior to Meal in Violation of Physician Order
Penalty
Summary
A resident with a diagnosis of diabetes mellitus and an intact cognitive status, as indicated by a BIMS score of 15, was admitted to the facility and had an active physician's order for rapid-acting insulin aspart to be administered subcutaneously with meals according to a sliding scale. On the day in question, a licensed nurse checked the resident's blood sugar, which was 167, and administered 1 unit of insulin aspart before the resident had eaten lunch. Both the nurse and the resident confirmed that the insulin was given prior to the meal, and lunch was not served until later. Facility policy requires that medications, including insulin, be administered in accordance with physician orders and within specified time frames, particularly for medications ordered to be given with meals. The Director of Staff Development confirmed that staff are expected to follow physician orders for insulin administration and acknowledged that the insulin was administered too early, not in accordance with the order. The facility's policies on medication and insulin administration were reviewed and supported the requirement for timing insulin with meals.
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 notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Develop Comprehensive Care Plan for Insomnia and Medication
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident who was admitted with multiple diagnoses, including dementia, depression, anxiety, and a personal history of other mental and behavioral disorders. The resident had a physician's order for trazodone to be administered at bedtime for insomnia, but the care plan did not address the resident's sleep issues or the use of trazodone. During interviews and record reviews, both a licensed nurse and the Director of Nursing confirmed that there was no specific care plan developed for the resident's sleep or insomnia. The facility's policy requires that a comprehensive care plan with measurable objectives and timetables be developed and implemented for each resident to address their physical, psychosocial, and functional needs. Despite this policy, the care plan for the resident in question did not include interventions for insomnia or the newly ordered medication, resulting in a failure to meet regulatory requirements for comprehensive care planning.
Plan Of Correction
Plan to Monitor Performance: 1. Medical Records will audit each resident for complete care plans after admission, when new orders are received, and quarterly to ensure completeness. Any missing care plans will be provided to staff to correct. A record of the audits will be provided to the DON to review and present to the quarterly QA committee. If needed, further corrective action will be created and implemented. All corrective action will be completed by 5/26/25. F 656
Failure to Update Care Plan After Resident Sustained Bruising
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a change in condition, specifically the development of a bruise on the right cheek. The resident, who had a diagnosis of vascular dementia, was admitted in April 2025. Documentation showed that on 4/17/25, the resident sustained facial bruising, and a physician's order was issued on 4/18/25 to monitor the discoloration every shift. Despite these events, the resident's care plan was not updated to reflect the new condition or the required monitoring interventions. Interviews with facility staff confirmed that the expectation was to update the care plan whenever a resident experienced a change in condition. A review of the care plan on 4/23/25 revealed that it did not include information about the bruising or the monitoring order. The facility's policy also required care plans to be revised as residents' conditions changed, but this was not followed in this instance.
Plan Of Correction
Plan to Monitor Performance: 1. Medical Records will audit all SBARs and COC reports to ensure that care plans are updated per this POC. Any missing or unrevised care plans will be presented to the DON and nurse responsible to be corrected. A record of the audits will be reported to the DON. 2. The Director of Nursing will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly for 3 months. The QAPI committee will evaluate the effectiveness of interventions and make changes as needed until substantial compliance is achieved and maintained. The facility will complete all corrective action with F657 by 5/26/25.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared, stored, served, and distributed in accordance with professional standards of food service safety. Observations revealed that the ice machine was not properly cleaned, with visible yellow-orange, pink, black, and yellow substances that could be wiped away, and rough surfaces inside the machine. The maintenance supervisor confirmed these findings and stated that cleaning was performed monthly, but the presence of residues indicated inadequate cleaning. The registered dietitian and facility policies confirmed that the ice machine should be cleaned and sanitized according to manufacturer instructions to prevent microbial contamination. Further deficiencies were observed in the maintenance and sanitation of kitchen equipment and food storage practices. The blade of the can opener was found to be chipped and worn, and nonstick cooking pans had significant scratches on their surfaces, both of which could lead to physical contamination of food. Multiple food items in refrigerators, dry storage, and the walk-in freezer were inconsistently dated, with some items lacking opened or used by dates, and some being past their manufacturer’s use-by dates. Opened food packages were not properly resealed, and thawing meat was not labeled with a pull date. Produce items, including tomatoes and oranges, were found to be spoiled with visible mold, and the certified dietary manager confirmed that staff had not been checking vegetables as required. Additional issues were identified with the resident food refrigerator, where the freezer section was not clean and lacked a thermometer for temperature monitoring. Temperature logs were incomplete, with missing entries for several days and incorrect temperature recordings for the freezer. The infection preventionist confirmed these findings and acknowledged that the charge nurse was responsible for monitoring temperatures. Facility policies required that refrigerators and freezers be kept clean, monitored, and maintained at appropriate temperatures, but these procedures were not followed, contributing to the overall deficiency.
Failure to Accurately Account for and Document Controlled Substances
Penalty
Summary
The facility failed to ensure accurate accountability and documentation of controlled substance medications for its residents. For two residents who had physician orders for hydrocodone/APAP, the Controlled Drug Record (CDR) indicated that doses were removed from the medication cart, but these administrations were not documented on the Medication Administration Record (MAR). This discrepancy was confirmed during interviews with the Director of Nursing (DON), who stated that nurses were expected to document every pill removed and administered, as outlined in the facility's policies. Additionally, the facility did not consistently obtain signatures from both the off-going and on-coming nurses on the controlled drug shift-to-shift count records for two medication carts. Review of these records revealed multiple missing signatures for various shifts, which was acknowledged by nursing staff and the DON. Facility policy required both nurses to count and sign for controlled medications at each shift change to ensure accountability. Furthermore, the removal of a narcotic medication from the emergency kit (e-kit) was not fully documented. During an inspection, a narcotic e-kit was found with a log indicating a tramadol tablet had been removed, but the date and time of removal were not recorded. Both the Infection Preventionist/Interim Staff Development and the DON confirmed that staff were expected to complete the log in full, in accordance with facility policy.
Plan Of Correction
Plan to Monitor Performance: 1. The DSD will monitor the controlled drug records at each cart to ensure they are signed by the outgoing and incoming nurses properly. Checks will be done daily for 1 month and then weekly for the next 4 months to ensure continued compliance. 2. The DON will audit emergency kit logs weekly for 4 weeks, then monthly for 3 months to ensure complete documentation. 3. Random controlled substance reconciliation audits will be conducted by the Consultant Pharmacist during monthly visits. The Director of Nursing will report audit findings to the Quality Assurance and Performance Improvement (QAPI) committee quarterly for review and recommendations. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained. All corrective action to be completed by 5/26/25.
Medication Labeling, Storage, and Expiration Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management practices during observations and interviews. Several multi-dose medications, including Tubersol, blood glucose test strips, and budesonide inhalation solution, were found opened and not labeled with the date of opening or discard date, despite manufacturer instructions and facility policy requiring such labeling. Additionally, expired medications such as ceftriaxone were present in storage areas, and some medications lacked pharmacy labels to identify the intended resident, including insulin pens, Sea Aloe supplement, and nitroglycerin tablets. Further inspection of medication carts revealed that prescription medications with different routes of administration, such as transdermal patches and oral medications, were stored together, contrary to facility policy. Loose pills were also found in medication drawers, and staff confirmed these should have been disposed of properly. Inhalers and other medications with limited stability after opening were not labeled with opened dates, as required by manufacturer guidelines and facility procedures. Interviews with staff, including the Infection Preventionist and a licensed nurse, confirmed awareness of the labeling and storage requirements, but acknowledged the deficiencies observed. The Director of Nursing also confirmed that medications should be labeled with at least the resident's name and that expired or loose medications needed to be removed and disposed of. Facility policies reviewed by surveyors supported these requirements for proper labeling, storage, and disposal of medications.
Plan Of Correction
Corrective Action for Affected Residents: On 4/21/25, the following immediate actions were taken: All corrective action to be completed by 5/26/25 F 761 F 761
Dietary Staff Lacked Competency in Manual Dishwashing Procedures
Penalty
Summary
The facility failed to ensure that two dietary aides were able to safely and effectively carry out the functions of the food and nutrition service, specifically regarding the manual dishwashing process using two-compartment sinks. During interviews, both dietary aides were unable to accurately verbalize the correct steps for manual dishwashing, including the proper sequence of wash, rinse, sanitize, and air-dry, as well as the required water temperatures and immersion times for sanitizing. One aide incorrectly stated the steps and was unsure about the necessary water temperature and sanitizer immersion time, while the other aide described using a large bucket as a third compartment and reported an insufficient immersion time of one to two seconds. Both aides had previously been checked off as competent in this procedure and had attended an in-service training on the topic. The Certified Dietary Manager and Registered Dietitian confirmed that staff responsible for dishwashing should have a thorough understanding of the manual dishwashing process, especially in situations where the dishwashing machine is unavailable. Review of facility policies indicated the correct procedure, including specific water temperatures and a 60-second immersion in sanitizer, which was not followed or understood by the aides. The deficiency had the potential to affect all 45 residents who received food from the kitchen, as the aides' lack of knowledge could compromise the safety and sanitation of dishware.
Failure to Follow Therapeutic Diet Menus and Portion Requirements
Penalty
Summary
The facility failed to follow prescribed therapeutic diets as outlined in their menu spreadsheets during lunch meal services. On two separate occasions, residents on Consistent Carbohydrate (CCHO) diets received incorrect desserts: three residents were served pineapple Bavarian cream square instead of pineapple tidbits, and another resident received pudding instead of the specified CCHO dessert. These discrepancies were confirmed by both the Certified Dietary Manager (CDM) and the Registered Dietitian (RD), who stated that the menu and spreadsheet should have been followed to ensure residents received the correct items for their dietary needs. Additionally, during another meal service, fifteen residents on fortified diets did not receive the required super soup, and two residents on large portion diets were served three ounces of meat instead of the prescribed four ounces. The facility's menu spreadsheets and diet manual specified the correct items and portion sizes for these diets. Both the CDM and RD acknowledged these failures during interviews, confirming that the meals provided did not match the ordered diets as required by facility policy and resident care plans.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to implement infection control practices for multiple residents, specifically by not initiating Enhanced Barrier Precautions (EBPs) for residents with wounds, indwelling medical devices, or infections. Several residents were identified as having conditions such as chronic wounds, PICC lines, wound vacs, MRSA infections, and other indwelling devices, all of which required EBPs according to facility policy. Observations and interviews confirmed that there was no EBP signage posted, and personal protective equipment (PPE) was not made available outside or inside the rooms of these residents, despite physician orders and policy requirements. Staff interviews, including those with licensed nurses and the Infection Preventionist (IP), confirmed that EBPs were not implemented as required for residents with wounds, indwelling devices, or infections. The IP and Director of Nursing (DON) acknowledged that the facility's EBP policy was not followed, and that residents who should have been on EBPs were not provided with appropriate signage or PPE. This lapse was observed across multiple residents, each with specific medical needs that warranted EBPs, such as open wounds, wound vacs, PICC lines, and active infections. Additionally, a Certified Nurse Assistant (CNA) was observed passing lunch trays to several residents without performing hand hygiene between residents. The CNA admitted to not following hand hygiene protocols, and the IP confirmed that staff were expected to perform handwashing or sanitizing between serving meals. The facility's hand hygiene policy required the use of alcohol-based hand rub or soap and water before and after handling food or assisting residents with meals, but this protocol was not followed during the observed meal service.
Failure to Maintain Comfortable Noise Levels for Residents
Penalty
Summary
The facility failed to maintain a comfortable noise level for four residents, resulting in decreased comfort and disrupted sleep. Observations and interviews revealed that staff frequently left room doors open at night, and certified nursing assistants often yelled to each other across hallways during care, contributing to excessive noise. Residents with insomnia and partially intact memory reported difficulty falling asleep and staying asleep due to the persistent noise, which included loud talking, laughing, and screeching by staff during both day and night shifts. One resident resorted to covering their head with a blanket to muffle the noise, while another used privacy curtains to reduce the sound from the hallway. Residents consistently described the environment as loud and disruptive, with noise issues persisting despite occasional temporary improvements after complaints. The facility's own policy emphasized the importance of maintaining comfortable noise levels to support a homelike environment, but staff actions and inactions, such as failing to close doors and engaging in loud conversations, directly contributed to the deficiency. The DON acknowledged that residents needed a calm environment for rest and healing, yet the facility did not prevent ongoing noise disturbances.
Plan Of Correction
MOUNTAIN MANOR SENIOR RESIDENCE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. MOUNTAIN MANOR SENIOR RESIDENCE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes MOUNTAIN MANOR SENIOR RESIDENCE's written credible allegation of compliance for the deficiencies noted. F 584 F 584 F 584
Failure to Develop Care Plan for Insomnia and Trazodone Use
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident who was admitted with multiple diagnoses, including dementia, depression, anxiety, and a history of other mental and behavioral disorders. The resident had a physician's order for trazodone to be administered at bedtime for insomnia. Upon review of the resident's medical record and care plans, both a licensed nurse and the Director of Nursing confirmed that there was no specific care plan addressing the resident's sleep issues or insomnia, despite facility policy requiring measurable objectives and timetables to meet each resident's needs.
Failure to Update Care Plan After Resident Sustained Bruising
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a change in condition, specifically a bruise to the right cheek. The resident, who was admitted with vascular dementia, sustained facial bruising as documented in the SBAR Communication Form and Progress Note. Following this incident, a physician's order was issued to monitor the discoloration on the resident's right cheek every shift. Despite these documented changes and the facility's policy requiring care plans to be updated as residents' conditions change, the care plan for this resident was not revised to reflect the new injury. Both a licensed nurse and the Director of Nursing confirmed during interviews that the expectation was to update the care plan after such changes, but this was not done in this case.
Failure to Clarify Unclear Medication Order Prior to Administration
Penalty
Summary
Licensed Nurse 2 (LN 2) failed to clarify a physician's order for calcium carbonate before administering the medication to a resident. During a medication pass, LN 2 prepared and gave one tablet of 500 mg calcium carbonate, despite the physician's order indicating 'calcium carbonate 1250 (500 Ca) mg, give one tablet by mouth two times a day.' LN 2 acknowledged that the order was unclear and should have been clarified with the physician prior to administration to ensure the correct dosage was given. The Director of Nursing (DON) confirmed that nursing staff are expected to clarify unclear orders with the physician and that nurses should contact the doctor whenever in doubt. The facility's medication administration policy also requires staff to consult the attending physician or medical director if a dosage is believed to be inappropriate or excessive. The failure to clarify the order resulted in the resident receiving a potentially incorrect dosage of medication.
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident with a communication barrier due to language. The resident, admitted with chronic respiratory failure, was assessed as having no memory problems and communicated only in Russian. The care plan specified the use of a communication board to facilitate communication between staff and the resident. However, during multiple observations and interviews, it was found that the communication board was not available in the resident's room, and staff were unable to effectively communicate with the resident without it. Staff, including a licensed nurse and a social worker, confirmed the absence of the communication board and acknowledged the difficulty in communicating with the resident as a result. The Director of Nursing also confirmed that the care plan required the use of a communication board and emphasized its importance for providing appropriate care. A review of facility policy indicated that communication boards should be provided for non-bilingual staff to communicate with residents who have language barriers, but this was not implemented for the resident in question.
Plan Of Correction
The DSD or designee (in conjunction with Social Services) will conduct daily audits of residents requiring communication boards for 2 weeks, then weekly for 1 month, and monthly thereafter to ensure devices are present and properly utilized. The Social Services Director will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee quarterly for 2 quarters or until substantial compliance is achieved and maintained. The QAPI committee will make recommendations for additional interventions or modifications as needed. All corrective action will be completed by 5/26/25.
Failure to Administer Oxygen per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of anxiety disorder was not provided respiratory care services in accordance with the physician's order. The physician had ordered oxygen to be administered at two liters per minute via nasal cannula as needed for shortness of breath. However, during an observation, the resident was found receiving oxygen at only one liter per minute while still experiencing shortness of breath. This discrepancy was confirmed by a licensed nurse, who acknowledged that the oxygen concentrator was set below the ordered rate. The Director of Nursing stated that the expectation was for nurses to follow the physician's order accurately to ensure proper care. A review of the facility's policy on oxygen administration also indicated the need to verify the physician's order, including the rate of oxygen flow.
Plan Of Correction
All corrective action will be completed by 5/26/25.
QAA Committee Lacked Required Medical Director Participation
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included all required members, specifically the Medical Director (MD), for a census of 45 residents. During a review of the facility's quarterly Quality Assurance and Performance Improvement (QAPI) meeting records, it was confirmed by the Administrator that the MD did not attend the QAPI meeting held in April 2024. The sign-in sheet for the meeting did not include the MD's name or signature, despite facility documentation and policy indicating that the MD is a required member of the QAA committee.
Antibiotic Prescribed Without Clinical Indication
Penalty
Summary
A resident was admitted to the facility without a diagnosis of urinary tract infection (UTI) and had a hospital urinalysis and culture that showed asymptomatic bacteriuria, with no symptoms or clinical indications for antimicrobial treatment. Despite this, an order for levofloxacin, an antibiotic, was initiated for the resident for chronic UTI and UTI prophylaxis, and the medication was administered over a period of several days. The resident did not exhibit any UTI symptoms such as painful or frequent urination, strong urine odor, or fever during their stay at the facility. The Infection Preventionist confirmed that the antibiotic was started based solely on the hospital urinalysis result, without supporting clinical symptoms. Facility policy on Antibiotic Stewardship requires that laboratory results and current clinical situations be communicated to the prescriber to determine if antibiotic therapy should be modified or discontinued. In this case, the policy was not followed, as the antibiotic was prescribed and administered without adequate clinical or laboratory findings to justify its use.
Plan Of Correction
5. All corrective action will be completed by 5/26/25.
Failure to Provide Bed Hold Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide proper bed hold notification to a resident who was transferred to the hospital on three separate occasions. Documentation review showed that the required written notice regarding the bed hold policy was not present in the resident's chart for any of the transfers. Specifically, there was no evidence of a completed bed hold notification form, no date or time of notification, no name of the person who provided the notification, and no indication of whether the bed hold was accepted or declined. Additionally, there was no signature from the resident or their representative to confirm that the notification was given. The resident involved had a diagnosis of congestive heart failure and was admitted to the facility in 2025. The resident was transferred to the hospital on three occasions, but in each instance, the facility did not provide the required written information about the bed hold policy as outlined in their own policy and federal regulations. Interviews with medical records staff confirmed the absence of proper documentation and notification for each transfer event.
Resident Elopement and Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent the elopement of a resident who was admitted with cognitive impairment, dementia, difficulty in walking, and a history of falling. The resident, who had a severe cognitive impairment score and was assessed as a moderate risk for wandering, left the facility unaccompanied. The incident occurred when the resident, who was in a wheelchair but able to ambulate with assistance, was left in the hallway for better visibility. During a time when the nursing staff was attending to another resident with a change of condition, the resident managed to wheel himself to the door and ambulate across the street to a neighboring facility. The resident was found lying on the ground by a passerby and complained of neck and knee pain, stating he had hit his head. The facility's policy on elopements, dated 2007, was reviewed and found to lack specific interventions to prevent such incidents. The administrator confirmed that the resident had no prior incidents of attempting to leave the facility and that staff had been monitoring him closely due to his fall risk. However, the lack of adequate supervision and preventive measures led to the resident's elopement and subsequent fall.
Resident Moved Without Advance Notice or Consent
Penalty
Summary
The facility failed to honor a resident's right to receive advance notice before a room change, resulting in a violation of the resident's rights. The resident, who was admitted in the spring of 2024 with heart problems and was his own responsible party, was moved to another room without prior notification or consent. On the day of the move, the resident was informed abruptly by a staff member and was left confused about the reason for the move, the location of the new room, and the identity of the new roommate. The resident expressed that he did not consent to the room change and suspected it might be due to a conflict with a staff member. The facility's policy, revised in May 2027, requires advance notice and consent for room changes, including an explanation of the reason for the move and an introduction to the new roommate. However, there was no documented evidence in the resident's medical record that such notice or consent was obtained. The Social Service Director confirmed that the room change was discussed during an Interdisciplinary Team meeting on the morning of the move, but no prior consent was documented. The Administrator acknowledged that the room change should have been discussed with the resident beforehand, and the Social Service Director verified the lack of documentation regarding the resident's consent or notification.
Food Safety Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to maintain food safety standards in several areas, as observed during a survey. The ice machine in the kitchen was found to have black and pink substances at the bottom of the ice evaporator unit and pink slimy substances on the water curtain. The Certified Dietary Manager (CDM) and the Registered Dietitian (RD) acknowledged the need for more frequent cleaning to prevent bacterial growth. The facility's Ice Machine Sanitation Log indicated that the last cleaning was done a month prior, and the manufacturer's manual emphasized the importance of regular cleaning to prevent slime and mold. In the dry storage area, 11 out of 15 tomatoes were found with black and white indented spots, indicating spoilage. The CDM confirmed the tomatoes were rotten and should be discarded. The RD also stated that produce should be fresh and checked daily for spoilage. The facility's policy on storing produce highlighted the need to discard spoiled items to prevent further spoilage. Additional deficiencies included several metal pans being stored while still wet and containing food debris, which the CDM confirmed was against the facility's policy of air-drying and cleaning pans before storage. Personal belongings of staff were found in the dry storage area, contrary to the facility's policy. Lastly, the juice dispenser was observed to have significant dust on the vent, which the RD acknowledged needed cleaning to prevent bacterial growth.
Failure to Replace Emergency Drug Kits
Penalty
Summary
The facility failed to maintain pharmacy services for its residents, as evidenced by two opened emergency drug kits in the medication room that were not replaced by the pharmacy according to the facility's policy. During an inspection, it was observed that e-kit #53, containing controlled medications, was accessed on 5/29/24, and e-kit #49, containing oral medications, was accessed on 5/30/24, 6/1/24, and 6/2/24. Despite these kits being used, they were not replaced by the pharmacy, which was confirmed by Licensed Nurse 1 during an interview. The Assistant Director of Nursing acknowledged that the failure to replace the e-kits could result in certain drugs not being available when needed. The ADON confirmed that the staff should have followed up with the pharmacy to ensure the e-kits were replaced with the next delivery, as the pharmacy delivers medications twice daily. The facility's policy, dated 4/2007, states that medications used from the emergency kit must be replaced upon the next routine drug order, which was not adhered to in this instance.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two errors identified during the observation of medication administration. For one resident, a licensed nurse administered famotidine, a medication for heartburn and stomach acid reflux, incorrectly by giving only one 10 mg tablet instead of the prescribed two tablets totaling 20 mg. This discrepancy was noted during a medication pass, and the nurse was unable to account for the incorrect pill count. The facility's policy requires medications to be administered according to physician orders, with a triple-check system to ensure accuracy, which was not adhered to in this instance. In another case, a resident did not receive their prescribed dose of metoprolol succinate, a medication for high blood pressure, because it was not available. The nurse discovered the absence of the medication during the administration process and contacted the pharmacy, which had failed to deliver the medication due to a packaging error. The facility's policy mandates that medications be available as prescribed, but this was not ensured, leading to the medication error. These incidents resulted in a medication error rate of 5.41%, exceeding the acceptable threshold.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. Six metered-dose inhalers were found in Medication Cart A without open dates, which is crucial for determining their expiration once opened. The inhalers included medications such as umeclidinium, vilanterol, fluticasone furoate, and budesonide, all of which have specific post-opening expiration periods. Licensed Nurse 1 and the Assistant Director of Nursing (ADON) acknowledged the oversight, with the ADON confirming that open date labels should have been applied to prevent the use of expired medications. Additionally, two expired insulin vials were discovered in the medication refrigerator. The vials of insulin glargine and lispro had surpassed their expiration dates, which should have been 28 days post-delivery due to the lack of cold storage during delivery. The ADON confirmed the expiration and acknowledged that the vials should have been removed from active storage. Furthermore, expired glucometer control solutions were found in Medication Cart A, which could lead to inaccurate glucometer readings for residents. The ADON confirmed the expiration and the potential impact on resident care. The survey also revealed prescription medication blister packs lodged in the rear gap of Medication Cart A, which could result in missed medication doses for residents. Loose pills were also found in the cart, indicating a lack of orderly storage. The ADON acknowledged these issues, confirming that medication storage areas should be kept clean and organized to prevent such occurrences. The facility's policies on medication storage and administration were reviewed, highlighting the requirement for proper labeling and the prohibition of using outdated or deteriorated drugs.
Dietary Menu Non-Compliance During Lunch Service
Penalty
Summary
The facility failed to adhere to the therapeutic diet menu during a lunch service, affecting five residents. Four residents on a consistent carbohydrate (CCHO) diet, intended for diabetes management, received a full serving of fruit mix crumble cake instead of the prescribed half serving. Additionally, a resident on a small portion diet also received a full serving of the dessert, contrary to the dietary guidelines. These discrepancies were observed during the lunch service, and the Certified Dietary Manager (CDM) acknowledged the errors, confirming that the menu specified a half serving for both CCHO and small portion diets. Furthermore, a resident on a mechanical soft texture diet, which is designed for individuals with chewing or swallowing difficulties, was served a chopped salad with croutons, despite the menu indicating that croutons should be excluded. The Registered Dietitian (RD) confirmed that the presence of croutons posed a risk to residents with swallowing difficulties. The RD emphasized the importance of following the menu to ensure the safety and nutritional needs of the residents. The facility's policy and job descriptions for dietary staff highlighted the necessity of adhering to the prescribed diets and ensuring tray accuracy, which was not followed in these instances.
Delayed MDS Admission Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) Admission Assessment within the required 14 calendar days after admission for two residents out of a census of 38. Resident 9, who was admitted with diagnoses including dementia and cognitive communication deficit, had their comprehensive Admission Assessment completed 28 days after admission. Similarly, Resident 21, admitted with altered mental status, had their assessment completed 26 days post-admission. During an interview and record review, the Director of Nursing acknowledged the late completion and submission of these assessments, which was not in accordance with the facility's policy and procedure for MDS completion and submission timeframes.
Failure to Develop Dialysis Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who was dependent on renal dialysis and had end-stage renal disease. The resident was admitted to the facility with a diagnosis that included dependence on dialysis, and it was observed that the resident had a peritoneal dialysis tube connected to her left abdominal area. The resident confirmed that she underwent dialysis on specific days of the week. Despite this, a review of the resident's medical records revealed that there was no care plan addressing her dialysis care and interventions. Interviews with facility staff, including a licensed nurse and the Assistant Director of Nursing, confirmed the absence of a care plan for the resident's dialysis needs. The facility's policy on comprehensive person-centered care plans requires the development and implementation of care plans that include measurable objectives and timetables to meet residents' needs. The lack of a care plan for the resident's dialysis care decreased the facility's potential to address her individualized and specific needs.
Resident Wears Immobilizer Without Physician's Order
Penalty
Summary
The facility failed to provide services that meet professional standards of quality care for a resident who was allowed to wear a left leg/knee immobilizer without a physician's order. The resident was admitted with a left tibial plateau fracture after a fall and was observed wearing the immobilizer during an initial tour. The physical therapist confirmed that the immobilizer should be worn at all times as ordered from the hospital to prevent the knee from bending or flexing. Upon review of the Order Summary Report, it was verified by a licensed nurse and the Director of Rehab that there was no physician's order for the immobilizer. The Assistant Director of Nursing, who admitted the resident, acknowledged forgetting to write the order after clarifying it with the hospital doctor. The facility's policy requires verbal orders to be recorded immediately, which was not followed in this case, leading to the deficiency.
Failure to Maintain Nail Care for Resident
Penalty
Summary
The facility failed to maintain proper nail care for a resident, identified as Resident 25, who was admitted with dementia. During an observation, it was noted that the resident had long fingernails packed with a brownish-black substance. The Certified Nurse Assistant (CNA) acknowledged the condition of the nails and stated the intention to inform the Licensed Nurse and Activities Aide for nail care. However, the Activities Aide was unaware of the issue, and the Licensed Nurse, who later discharged the resident, was also not informed. Another CNA noticed the condition but forgot to report it. The resident's care plan indicated a deficiency in self-care, but there was no specific nail care plan initiated. The facility's policy required daily cleaning of nails, which was not followed. The Assisting Director of Nursing stated that CNAs should have performed daily hand hygiene and cleaned the nails with soapy water if trimming was not possible. The failure to maintain nail hygiene decreased the facility's potential to prevent infection, as dirty nails are a known source of infection.
Failure to Implement Physician's Order for Heel Floating
Penalty
Summary
The facility failed to provide care in accordance with professional standards for one resident, identified as Resident 2, who did not receive the prescribed treatment to float her heels while in bed. This order was intended to prevent skin breakdown. Resident 2 was admitted with diagnoses including muscle weakness and age-related physical debility. During an observation and interview, it was noted that Resident 2's feet were not floated as per the physician's order, despite the presence of edema. Licensed Nurse 4 confirmed the oversight and acknowledged the active order for heel floating. The Assistant Director of Nursing stated that nursing staff are expected to follow physician orders and that any refusal by the resident should be communicated to the doctor and documented in the care plan. The facility's policy on medication and treatment orders requires adherence to safe and effective order writing and implementation.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 15, had access to necessary vision services, specifically prescription eyeglasses. Resident 15, who was admitted in July 2023 with diagnoses including cataracts and syncope, was observed squinting while watching television and using a magnifying glass for reading. Despite the resident's need for corrective lenses being documented in her Minimum Data Set assessment dated April 2024, the facility had not provided the required eyeglasses. Interviews with facility staff, including the Social Worker and the Assistant Director of Nursing, confirmed that Resident 15 required eyeglasses to watch television properly and that the Social Worker had not yet facilitated the necessary referrals for obtaining them. The facility's policy on referrals, revised in December 2008, indicated that social services personnel are responsible for coordinating resident referrals based on their needs. This oversight resulted in Resident 15 not having the eyeglasses needed to maintain good vision.
Failure to Ensure Residents are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications. Resident 2 was prescribed an anti-anxiety medication, hydroxyzine hydrochloride, without a stop date, despite a recommendation from the Pharmacy Consultant to include one. The medication was administered three times in May 2024, and the Nurse Practitioner confirmed the absence of a stop date during a review. The Assistant Director of Nursing acknowledged the oversight, noting that the medication should have been limited to a 14-day period as per the facility's policy. Resident 3 was prescribed an antibiotic, ciprofloxacin hydrochloride, for recurring urinary tract infections without a specified duration of treatment. The Pharmacy Consultant noted the absence of a stop date but did not provide recommendations. The Nurse Practitioner agreed that the medication had been ordered for too long, and the Infection Preventionist confirmed that the last documented UTI was in June 2022. The facility's policy requires complete antibiotic orders, including start and stop dates, which was not adhered to in this case.
Infection Control Breach in COVID-19 Unit
Penalty
Summary
The facility failed to adhere to infection control practices for a resident diagnosed with COVID-19. During an observation, a Certified Nursing Assistant (CNA) entered the room of a COVID-19 positive resident without wearing a face shield or goggles, despite the visible signage indicating the requirement for such personal protective equipment (PPE). The CNA was observed wearing an N-95 mask, gown, and gloves while assisting the resident with a meal, but did not comply with the full PPE protocol as outlined by the facility's policy. Interviews with the CNA and a Licensed Nurse confirmed the PPE requirements for the COVID-19 unit, which included the use of an N-95 mask, gown, gloves, and either goggles or a face shield. The facility's policy, dated May 2023, also specified these PPE requirements for staff caring for residents with suspected or confirmed COVID-19 infection. The Infection Preventionist reiterated the necessity of these PPE measures during an interview, highlighting the deviation from established protocols in this instance.
Failure to Post Daily Staffing Information Timely
Penalty
Summary
The facility failed to ensure that staffing information was posted daily at the beginning of each shift for a census of 38 residents. Observations revealed that the Daily Staffing information was not posted on the weekend of 6/1/24 and 6/2/24, and during weekdays, it was posted late, after 9:30 a.m., instead of within two hours of the beginning of the day shift at 6 a.m. This lapse was confirmed by the Staffing Coordinator, who acknowledged the failure to post the staffing information timely and attributed the weekend oversight to the receptionist. Interviews with the Staffing Coordinator and the Assistant Director of Nursing confirmed that the responsibility for posting staffing information was not fulfilled as per the facility's policy. The policy, dated 7/16, mandates that the facility post the number of nursing personnel responsible for providing direct care to residents daily and within two hours of the start of the day shift. The failure to adhere to this policy resulted in residents and visitors being unable to access information about the staff ratio and the number of staff providing care.
Failure to Follow Therapeutic Diet Menus and Portion Sizes
Penalty
Summary
The facility failed to ensure that therapeutic diets were provided according to the prescribed menu and physician orders during lunch meals on two consecutive days. Specifically, three residents on a Consistent Carbohydrate (CCHO) diet received pineapple Bavarian cream square instead of the prescribed pineapple tidbits, and another resident on the same diet received pudding instead of the correct CCHO dessert. The facility's menu spreadsheet indicated that pineapple tidbits should have been served, and both the Certified Dietary Manager (CDM) and Registered Dietitian (RD) confirmed that the observed desserts did not comply with the menu requirements for CCHO diets. Additionally, during a meal service, fifteen residents on fortified diets did not receive the required super soup, which is intended to provide extra calories and nutrients for those unable to consume adequate amounts of food. The menu spreadsheet specified that super soup should be provided for fortified diets, but it was omitted during the meal service. Furthermore, two residents on large portion diets received only three ounces of meat instead of the four ounces specified in the menu spreadsheet. The RD explained that large portion diets are necessary for residents who need more protein or have specific preferences, and the correct portion size is essential to meet their nutritional needs. These failures were observed during direct dining and meal service observations, and were acknowledged by both the CDM and RD. The facility's own diet manual and job descriptions for dietary staff require strict adherence to menu specifications and portion sizes for therapeutic diets. The deficiencies had the potential to compromise the medical and nutritional status of a significant number of residents who received meals from the facility's kitchen.
Plan Of Correction
Corrective Action for Affected Residents: On 4/23/25, the Registered Dietitian reviewed the nutritional status of Residents 11, 21, 35, and 17 who received incorrect CCHO desserts, and Residents 1, 2, 3, 7, 15, 18, 20, 21, 25, 28, 30, 38, 39, 41, and 396 who did not receive super soup for fortified diets, and Residents 6 and 17 who received incorrect portion sizes. No adverse effects were identified. The Certified Dietary Manager immediately corrected portion sizes and therapeutic diet components for all affected residents. Identifying other Residents having the Potential to be Affected: On 4/23/25, the Registered Dietitian conducted a comprehensive review of all residents receiving therapeutic diets to ensure proper menu items and portion sizes were being provided. The CDM reviewed all current therapeutic diet orders against the menu spreadsheet to ensure alignment. Measures put into place or Systemic Changes: 1. The CDM will in-service all dietary staff: - Proper portion sizes for therapeutic diets - Following menu spreadsheets accurately - Importance of therapeutic diet compliance - Proper documentation of menu substitutions 2. Kitchen staff will measure protein portions using standardized serving utensils and scales to ensure accurate portions. Plan to Monitor Performance: 1. The CDM or designee will audit 10 therapeutic diet trays daily for 2 weeks, then 3x/week for 2 weeks, then weekly for 1 month to ensure compliance with menu spreadsheet and proper portions. 2. The RD will conduct weekly random audits of 5 therapeutic diet trays for 4 weeks, then monthly for 2 months. 3. Results of all audits will be reported to the Quality Assurance and Performance Improvement (QAPI) committee quarterly by the Food Service Director. The QAPI committee will analyze data for patterns and trends and make recommendations for continued monitoring or modification of plan as needed until substantial compliance is achieved and maintained. All corrective action to be completed by 5/26/25. 2. The Maintenance Supervisor will be in-serviced by the CDM on proper ice machine cleaning procedures per manufacturer's guidelines. 3. The Director of Nursing will in-service all nursing staff on proper temperature monitoring and documentation for resident unit refrigerators/freezers. Plan to Monitor Performance: 1. The CDM or designee will conduct weekly audits for 4 weeks, then monthly for 12 months of: - Ice machine cleanliness - Equipment condition - Food storage practices - Temperature logs - Food labeling compliance 2. The Director of Nursing or designee will audit resident unit refrigerator/freezer temperature logs daily for 4 weeks, then weekly for 12 months. 3. Results of all audits will be reported to the Quality Assurance Performance Improvement (QAPI) Committee quarterly for review and additional interventions as needed until substantial compliance is achieved and maintained for 3 consecutive months. All corrective action to be completed by 5/26/25.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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