Mountain View Conv Hosp
Inspection history, citations, penalties and survey trends for this long-term care facility in Sylmar, California.
- Location
- 13333 Fenton Avenue, Sylmar, California 91342
- CMS Provider Number
- 056333
- Inspections on file
- 109
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Mountain View Conv Hosp during CMS and state inspections, most recent first.
Improper Garbage and Refuse Disposal: Two dumpsters were observed not fully closed and propped open with wood, with gloves, trash, and liquid drippings in the surrounding area. In the dishroom, a trash can by the handwashing sink was observed without a cover while not in use. The DS and MS stated garbage and trash containers should be kept closed or covered, and facility policy required refuse to be properly contained.
A facility failed to keep call lights or pad call lights within reach for multiple residents who were at risk for falls and had varying levels of cognitive and mobility impairment. Observations found devices placed on the bed far from the resident’s head or on the floor, despite care plans directing staff to ensure the call light was accessible so the resident could summon assistance.
Failure to Provide Written Advance Directive Information The SSD failed to provide and document written advance directive information for three residents. One resident had severe cognitive impairment and lacked decision-making capacity, while the other two were described as having capacity or normal cognition. RN and SSD record reviews found no scanned advance directive acknowledgment forms, and the SSRs stated the residents or representatives were not provided the required written information. The ADON stated the SSD was responsible for offering and documenting the advance directive information, and facility policy required written notice of the right to accept or refuse treatment and to formulate an advance directive.
PASRR Screening Not Updated for Residents With Mental Health Diagnoses: The facility failed to resubmit PASRR Level I screenings when admission records showed mental health diagnoses that did not match the prior screenings. Three residents had records showing bipolar disorder, unspecified psychosis, PTSD, and psychotropic medication use, yet their PASRR Level I screenings stated they had no SMI/ID/DD/RC and did not need Level II review. The SAC stated the screenings should have been updated to reflect the current diagnoses.
The facility failed to develop and implement comprehensive person-centered care plans for two residents with documented mental health diagnoses. One resident was admitted with schizophrenia and another with bipolar disorder, and both H&P and MDS records confirmed those diagnoses, yet no care plans addressed either condition. Facility staff confirmed the omissions and stated that care plans should be developed soon after admission and based on the resident’s assessed needs.
Failure to Rotate Insulin Injection Sites: Licensed nursing staff did not rotate SQ insulin injection sites for two residents with DM2 who had orders and care plan interventions directing site rotation. One resident received repeated insulin doses in the same abdominal area, and another received repeated doses in the same abdominal area and left arm. The ADON stated this was a medication error and confirmed staff failed to rotate sites as documented in the LAR.
Catheter care and labeling practices were not followed for three residents. One resident with a suprapubic catheter had looped tubing with urine trapped in the loop, another resident with a Foley catheter had dependent tubing loops with urine and sediment present, and a third resident’s urinal was not labeled with the resident’s name, room number, or date. Staff stated the tubing should be free of loops or kinks to allow urine to flow freely, and the ADON confirmed urinals should be labeled for infection prevention.
Failure to Rotate Insulin Injection Sites: Two residents with DM2 had insulin orders and care plans directing staff to rotate injection sites, but the LARs showed repeated injections in the same abdominal area and repeated use of the same arm site. The DON/ADON confirmed that not rotating insulin sites is a medication error and stated the practice is used to prevent skin damage and related insulin absorption problems.
Kitchen staff were observed failing to follow food safety and sanitation practices. A cook did not use a thermometer to verify the internal temperature of vegetables while cooking, a dietary aide did not fully air-dry a blender before it was reused for puree foods, and another dietary aide used the wrong test strips to check sanitizer concentration. The facility’s competency records did not show these skills were verified.
Late Lunch Meal Service: Meal service was delayed when lunch did not start at the scheduled noon time because pureed foods were below the facility's 165 F standard and had to be reheated. A Dietary Aide was observed taking temps on the trayline, the RD corrected the thermometer technique, and the DS stated the delay occurred because food temps could not be met. The first cart did not leave the kitchen until 12:30 p.m., despite the posted meal schedule and facility policy listing lunch at 12 p.m.
Kitchen staff failed to follow safe food storage, sanitation, and hand hygiene practices. Thawed ground beef was returned to the freezer, a walk-in cooler gasket was torn and dirty, dented cans were stored with intact cans, and outdated or unlabeled items were found in resident refrigerators. Staff also failed to properly temp food during cooking, fully air-dry and sanitize a blender, perform adequate handwashing, and avoid direct contact between food and an unsanitized stove surface.
Arbitration Agreement Missing Required Communication Language: The facility’s arbitration agreement for three residents did not include required language stating that the resident or a representative could communicate with federal, state, or local officials, including surveyors and the Ombudsman. One resident had impaired cognition and could not make medical decisions, while the other two had capacity and intact cognition. The AC and ADM acknowledged the language was missing from the agreement, and the facility policy stated the agreement may not prohibit or discourage these communications.
The facility had multiple infection control failures involving a CNA who removed gloves after brief care without hand hygiene, linen carts for residents’ personal clothing that were covered with permeable material instead of protective cart covers, water temperatures that repeatedly fell within the Legionella growth range, and an LVN who disinfected a reusable glucometer with only a single swipe before and after use on a resident on EBP. Facility staff and policies confirmed the expected hand hygiene, linen protection, water management, and equipment disinfection practices.
Flies were observed in the dishroom flying and landing on dirty dishes, trash, and clean dishes during food service operations. The DS stated the flies were present in the dishwashing area, did not know why they were there, and acknowledged that clean dishes needed to be kept away from flies. The facility's Pest Control policy stated that the facility shall maintain an effective, ongoing pest control program.
A resident with severe cognitive impairment and multiple comorbidities accused a CNA of hitting her during ADL care and remained visibly upset, but the CNA did not report the allegation, another CNA only informed an LVN, and the LVN checked for injuries and then continued medication administration without notifying the Adm or removing the alleged perpetrator from the assignment. The Adm did not learn of the allegation until several hours later, after the ADON was informed by the nurse assigned to the resident and confirmed that the allegation had occurred earlier that morning. Facility leadership and the DSD acknowledged that all staff are mandated reporters and that facility policy requires immediate reporting of any abuse allegation to the Adm and to CDPH, the Ombudsman, and LLE within two hours, as well as removal of the accused staff from resident contact, but these steps were not followed in this case.
Incomplete informed consent for bilateral bolsters: A resident with chronic respiratory failure, a tracheostomy, quadriplegia, and severely impaired cognition had bilateral bolsters ordered for comfort, positioning, and safety. The consent documented phone approval from the responsible party, but it did not state the reason for the device. Staff confirmed the bolsters were strapped to the bedframe and used for safety and positioning, and acknowledged the consent should have included the specific reason for use.
Dilapidated Bedside Drawer in Resident Room: A resident with major depressive disorder, anxiety disorder, and impaired mental status was observed with a bedside drawer in poor condition, held together with multiple pieces of tape and able to fall apart when pulled out. The DON stated the drawer could fall off and hurt the resident and was not promoting a homelike environment, and the ADON stated broken furniture in the resident’s room was not appropriate and did not follow the facility’s Homelike Environment policy.
Failure to Document and Provide Transfer Report During Resident Discharge: A resident with dementia, difficulty walking, and HF was discharged to another SNF, but the discharging RN did not document a verbal report to the receiving facility. The discharge summary and discharge instruction form also did not identify the next provider, provider type, or that report was given. RN and ADON stated that the receiving facility should have been called with the resident’s current status, functioning, isolation status, and meds, and the facility P&P required a transfer summary and telephone report.
Medication Left at Bedside: A resident with ESRD, renal dialysis dependence, and moderate cognitive impairment had a bottle of Refresh eye drops left on the bedside table. The HDS observed the medication in the room, and the ADON stated the resident had no self-administration assessment and that leaving medication at the bedside was not appropriate. The ADON also stated staff did not follow the facility’s medication storage and resident safety policies.
Two residents with GTs and continuous tube feeding had water flush bags observed with the same hang date/time beyond the manufacturer’s 24-hour limit. An LVN stated the facility changed the water flush bag only when the feeding bag finished and was unaware of the 24-hour limit. The SAC confirmed the facility did not follow the manufacturer’s guidance for the feeding set.
Respiratory care was not provided in accordance with infection prevention policy for two residents. One resident with acute respiratory failure and an order for PRN O2 had nasal cannula tubing observed stored in a plastic bag with an old date, and staff stated it should have been changed weekly. Another resident with COPD and a non-invasive ventilator had a 1000 ml bottle of sterile water for inhalation left in the room after opening, even though staff stated it was single-use and should be discarded within 24 hours. The DON/ADON stated the facility’s respiratory infection prevention policy was not followed.
Expired meds were found in a med storage room and a med cart, including an expired vitamin-like supplement and an insulin lispro pen kept beyond the 28-day open period. During insulin administration for a resident with DM 2, an LVN prepared the dose based on memory and did not check the eMAR before setting the insulin pen dose, despite the resident’s sliding-scale order and the facility’s insulin administration procedure requiring verification of the order before preparation.
Two medication carts had labeling deficiencies involving an eye drop bottle and a multidose potassium citrate-citric acid bottle. An LVN and the DON/ADON observed that one eye drop bottle lacked the resident name, readable room number, and open date, while the other bottle had no open date; staff stated opened eye drops and multidose bottles require dating to track use and expiration. One resident involved had aphasia, dysphagia, kidney stones, and severe cognitive impairment.
Failure to Clarify Continued Antibiotic Use: A resident admitted with acute respiratory failure with hypoxia, tracheostomy, and otitis media was ordered amoxicillin-pot clavulanate via GT. The Antibiotic Time Out showed no fever, no trending vital signs, and no signs or symptoms of infection, yet the physician was told to continue the antibiotic. The IP and SAC stated the resident did not meet criteria for continuation and that the indication for continued use was not clarified, despite the facility’s antibiotic stewardship policy requiring monitoring of antibiotic use.
Failure to Administer Pneumococcal Vaccine: A resident with a history of acute respiratory failure s/p tracheostomy, PTSD, psychosis, dysphagia, acute kidney failure, and colon cancer did not receive the pneumococcal vaccine per the facility’s P&P. The IP Nurse reviewed the immunization record and noted prior Pneumovax doses, stated the vaccine should have been given after five years, and found no documentation of refusal. The DON stated pneumonia vaccine is offered on admission and that residents without it may be at risk for respiratory problems.
A resident with hemiplegia, DM, HTN, and high pressure-ulcer risk (Braden score 11) had a care plan and IDT recommendations that included use of a low air loss (LAL) mattress for wound and skin management. The LAL mattress order was later discontinued when the resident’s skin was noted as intact, but the MD and responsible party were not notified at the time of this change in treatment. A family member subsequently complained about the mattress removal and was told by a treatment nurse that no MD order or notification was needed, citing facility protocol. In interview, the DON acknowledged that an order was required to start and stop the LAL mattress, that this constituted a change in treatment requiring MD and representative notification, and that failure to notify violated the resident’s and representative’s right to be informed and make decisions.
A resident with essential HTN and cognitive impairment had physician orders for atenolol and losartan to be held if SBP was below 110 mmHg, but an LVN documented administering these medications on several occasions when SBP readings were below the ordered parameter. The MAR showed check marks indicating administration despite low BP values, and the LVN later stated he had held the medications but could not provide proof. Interviews with an RN and the DON confirmed that nursing staff were expected to follow the ordered BP parameters and the facility’s medication administration policy requiring verification of vital signs and adherence to prescriber orders.
A resident with multiple medical conditions, including a UTI, received two different antibiotics (cephalexin followed by ciprofloxacin) as ordered by a physician, with administration documented on the MAR. The existing care plan addressed a history of UTI only in general terms, instructing staff to administer medications as ordered and monitor for side effects, but it did not identify or individualize care for the specific antibiotics prescribed. The IP stated that antibiotic use should be care planned on the day therapy starts and revised with any change in antibiotic, and confirmed that no such antibiotic-specific care plan was developed. The DON referenced facility policy requiring person-centered care plans with measurable objectives, timeframes, and revisions as conditions change, and acknowledged the resident’s care plan should have been revised to reflect the antibiotic therapy.
A resident was admitted with multiple documented pressure ulcers and deep tissue injury, along with severe cognitive impairment and dependence on staff for ADLs. Admission assessments and subsequent IDT wound management notes identified several pressure ulcers on the shoulder, arm, hip, knee, and leg, and treatment orders for daily betadine and dressings were initiated. Despite this, the WCP was not notified of the wounds at admission or during the next two weekly visits, in accordance with a practice described by the TN of only notifying the WCP during weekly rounds. As a result, the WCP did not assess the resident’s wounds or perform needed surgical debridement until 12 days after admission, when multiple pressure ulcers were finally evaluated and one hip ulcer was surgically debrided. The DON acknowledged that delayed debridement could slow wound healing.
A resident with multiple medical conditions and severe cognitive impairment received cephalexin and then ciprofloxacin for a UTI, with care plans and physician orders requiring monitoring for side effects. Facility policy and the IP, RN, and DON all indicated that residents on antibiotics must be monitored every shift for signs and symptoms of infection and adverse reactions, with documentation in progress notes or skilled notes. Review of the MAR and clinical record showed that while the antibiotics were administered as ordered, nursing staff did not document required monitoring for adverse effects during several identified shifts, contrary to the facility’s antibiotic stewardship, infection surveillance, and medication administration policies.
A nurse left a resident's EHR open and unattended at a nurses' station, exposing confidential health information. The nurse admitted to not logging off the computer before leaving, and the DON confirmed this violated facility policy for protecting e-PHI. The resident involved had dementia and required significant assistance with daily care.
A resident with dementia and a history of falls was placed on a bed alarm following a fall, but informed consent from the responsible party was not obtained until nearly two weeks after the device was implemented. The DON confirmed that consent should have been secured at the time of the order, in accordance with facility policy.
A resident with a history of GI bleed and dementia had both NPO and clear liquid diet orders active at the same time, resulting in conflicting instructions in the medical record. Staff interviews and record reviews confirmed the orders were not updated accurately, leading to confusion about the resident's care and failure to maintain complete and accurate documentation as required by facility policy.
A resident with multiple diagnoses, including UTI and diabetes, underwent an intermittent catheterization procedure that was not documented in the medical record by the LVN who performed it. Both the LVN and DON acknowledged that the procedure and the resident's response should have been recorded, as required by facility policy and professional standards.
A resident with intact cognitive function reported that an x-ray technician entered her room at night without knocking, introduction, or explanation, causing distress. The complaint, voiced to a CNA, was not reported to licensed nurses or documented as a grievance, contrary to facility policy. Staff interviews and record reviews confirmed the failure to address and document the resident's concern.
The facility did not provide medical records within the required 48-hour timeframe for two residents after receiving written requests, resulting in significant delays. One resident's records were delayed due to attempts to collect additional documentation, while another resident's family did not receive records or an invoice within the policy window, contrary to facility policy.
A resident with end stage renal disease and dependent on dialysis was transferred from a dialysis center to a hospital and did not return, resulting in the facility not retrieving the Dialysis Communication binder. Staff interviews confirmed that the binder, essential for documenting and communicating care, was not recovered, leading to incomplete medical records in violation of facility policy.
A resident with multiple serious diagnoses experienced hematuria, a significant change in condition. Although lab tests were ordered and results indicated infection, there was no documentation that a COC note was created or that the physician and resident's representative were notified at the time of the change, as required by facility policy. Staff interviews confirmed the lack of timely notification and documentation.
A resident with a history of prostate cancer, chronic kidney disease, and acute respiratory failure experienced hematuria, but staff did not create or update a care plan to address this change in condition. Although physician orders for urinalysis and urine culture were obtained, no change in condition note or care plan interventions specific to hematuria were implemented until several days later, delaying appropriate monitoring and response.
A resident with severe cognitive impairment was found with a bruise and swelling on the face, which was not reported to the Survey State Agency as required by the facility's abuse prevention policy. The injury was noted by a CNA and reported to an LVN and RN, but despite the policy mandating immediate reporting to authorities, it was only reported to a doctor.
A facility failed to create a baseline care plan for a resident with epilepsy within 48 hours of admission. Despite the resident's severe cognitive impairment and history of seizures, the care plan lacked specific seizure precautions. Staff interviews confirmed the absence of a care plan for seizure precautions and fall risk, which should have been established upon admission. The facility's policy required a baseline care plan to address immediate health and safety needs, but this was not implemented for the resident.
The facility failed to provide a clean and comfortable environment for its residents. A resident's electric fan was found dusty, and three residents experienced room temperatures below the required range, leading to discomfort and complaints. Despite being informed, the maintenance department did not adequately address the issues, impacting the residents' quality of life.
The facility failed to implement comprehensive care plans for residents requiring supplemental oxygen, diabetes management, and the use of physical restraints. One resident frequently removed their nasal cannula, yet no care plan addressed this behavior. Another resident receiving diabetes treatment lacked a care plan for monitoring blood sugar levels. Additionally, a resident using grab bars/side rails had no care plan or physician's order, and a resident on amitriptyline for depression had no measurable goals for treatment monitoring.
A facility failed to provide adequate range of motion (ROM) and mobility services for three residents. One resident did not receive passive range of motion (PROM) exercises on the knees as ordered, and this was not reported to therapy staff. Another resident's ROM was not appropriately monitored, as the facility's system relied on visual assessments rather than objective measurements. A third resident had a discrepancy in RNA orders, with PROM exercises ordered less frequently than splint application, which should be preceded by PROM. The facility's policies for maintaining and improving mobility were not effectively implemented.
The facility failed to maintain a safe environment for residents, with fall mats improperly used, a non-functional bed pad alarm, frayed wires on a bed remote, an elevated bed, and an oxygen concentrator placed unsafely. These deficiencies increased the risk of injury, as confirmed by staff and the DON, and violated facility policies on fall risk management and hazardous equipment.
The facility failed to manage enteral feeding appropriately for three residents. A resident's feeding was administered without checking residuals, contrary to physician orders. Another resident's water flush bag lacked labeling for the delivery rate, risking improper hydration. Additionally, a third resident's feeding and water flush bags were not labeled with the administration rate, potentially affecting their nutritional intake. These deficiencies were confirmed by staff and the DON, highlighting lapses in following established protocols.
The facility failed to properly dispose of medications and maintain accurate records in one medication room. Medications were found in their original packaging without being rendered irretrievable, contrary to policy. Additionally, six records lacked verifying signatures of two licensed nurses, as required. The DON acknowledged these deficiencies could lead to medication diversion and accidental exposure.
The facility failed to monitor Trazodone side effects for a resident and did not limit PRN lorazepam orders to 14 days for another resident, as required by policy. The lack of documentation and adherence to protocols led to deficiencies in medication management, putting residents at risk for unnecessary medication use and potential adverse effects.
A facility failed to maintain a medication error rate below 5%, resulting in a 17.86% error rate due to incorrect medication administration to three residents. Errors included wrong doses and omissions of prescribed medications. Observations revealed that two LVNs did not follow the facility's medication administration guidelines, leading to these errors.
The facility failed to prepare puree foods to the required consistency for residents on a level 4 diet, as observed during a lunch trayline. Puree Boston baked beans did not hold their shape, and puree cabbage was weeping liquid, contrary to the facility's policies and IDDSI guidelines. This inconsistency in food texture posed potential risks for 11 residents on the puree diet.
Improper Garbage and Refuse Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly when two dumpsters in the dumpster area were observed not fully closed and were propped open with a piece of wood while not actively in use. The surrounding area also contained gloves, trash, and liquid drippings. During interview, the Dietary Supervisor stated the garbage needed to always be closed, and the Maintenance Supervisor stated the dumpster lid should always be closed, but staff had placed wood to hold the lid open because the trash was heavy and they forgot to close it. The Maintenance Supervisor also stated he cleaned the dumpster area once a week or as needed. In the dishroom area, a trash can by the handwashing sink was observed without a cover while not actively being used. The Dietary Supervisor stated the trash can was used for soiled paper towels and that all trash cans should be covered to keep flies away from the area. Facility policy titled Sanitation stated garbage and refuse containers are to be properly contained in dumpsters or compactors with lids or otherwise covered, and kitchen wastes are to be kept in clean, leakproof, nonabsorbent, tightly closed containers and disposed of daily.
Call Lights Left Out of Reach for Multiple Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that pad call lights or call lights were within reach for five sampled residents. During observations, Resident 66, Resident 40, Resident 90, Resident 31, and Resident 37 were each found with their call light placed out of reach, including on the uppermost corner of the bed or on the floor. The report states that these residents were unable to effectively access the devices to summon staff assistance when needed. Resident 66 was admitted with diagnoses including acute respiratory failure with hypoxia, tracheostomy, and cardiac arrest. The resident’s H&P indicated no capacity to understand and make decisions, and the MDS described severely impaired cognition, inability to understand needs, impairment of both upper and lower extremities, and total dependence for all ADLs. The care plan for falls included placing the call light within reach. During observation, the pad call light was on the uppermost right corner of the bed and not touching the resident’s head, and staff stated it should have been placed closer to the head so the resident could touch it for assistance. Resident 40 had diagnoses including acute respiratory failure, tracheostomy, and cardiac arrest, with documentation showing no capacity to understand and make decisions, severely impaired cognition, impairment of both upper and lower extremities, and total dependence for all ADLs. The fall risk assessments and care plan identified the resident as at risk for falls and directed staff to ensure the call light was within reach. During observation, the pad call light was again placed on the uppermost right corner of the bed and away from the resident’s head. Resident 90, Resident 31, and Resident 37 were also identified as residents at risk for falls, with care plans or related tools directing staff to keep the call light within reach. In each of those rooms, the call light was observed on the floor rather than within reach, and staff stated the device should have been accessible so the resident could call for help.
Failure to Provide Written Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information to adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident’s option, formulate an advance directive. The deficiency involved three sampled residents, and the Social Services Director (SSD) acknowledged that written advance directive information had not been provided or documented for those residents. Resident 9 was admitted and later readmitted with diagnoses including encephalopathy, dysarthria, hemiplegia, and hemiparesis following cerebral infarction. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated the resident rarely to never could make self understood or understand others and had severe cognitive impairment. The MDS also noted family and a significant other were actively participating in assessment and goal setting. The SSR stated the resident/representative was not provided advance directive information, and RN 1 and the SSD both stated no scanned advance directive acknowledgment form was found in the electronic record. Resident 17 was admitted with diagnoses including hepatic encephalopathy, COPD, and heart failure. The H&P stated the resident was awake, alert, oriented, cooperative, able to follow commands, and had capacity to understand and make decisions. The MDS indicated the resident could make self understood, understand others, had normal cognitive function, and was independent with bed mobility, transfers, dressing, toileting, eating, and personal hygiene. The SSR stated the resident/representative was not provided advance directive information, and RN 1 and the SSD stated no scanned acknowledgment form was present in the record. Resident 3 was originally admitted and later readmitted with diagnoses including PTSD, unspecified psychosis, other psychoactive substance abuse, dysphagia, acute kidney failure, and history of colon cancer. The H&P stated the resident had the capacity to understand and make decisions, and the MDS indicated the resident could make needs known, understand others, had moderate cognitive impairment, and required assistance with mobility, transfers, dressing, toileting, and personal hygiene. The SSR stated no advance directive information was provided, and RN 1 and the SSD stated no scanned advance directive acknowledgment form or written formulation information was found in the record. The ADON stated the SSD was responsible for offering advance healthcare directive information and documenting that it was provided, and the facility policy stated residents or representatives are to be provided written information concerning the right to refuse or accept treatment and to formulate an advance directive.
PASRR Screening Not Updated for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that residents were screened using PASRR before admission and that residents identified with a mental disorder or intellectual disability/developmental disability/related condition received the required Level I review when the admission information did not match the prior PASRR screening. This deficiency was identified for 3 of 3 sampled residents: Resident 4, Resident 10, and Resident 3. Resident 4 was admitted with diagnoses including respiratory failure, tracheostomy, and bipolar disorder. The admission record and H&P indicated the resident did not have capacity to understand and make decisions. The PASRR Level I screening dated at admission stated the resident did not have a serious diagnosed mental disorder, no suspected mental illness, and had not been prescribed psychotropic medications. During interview, the Subacute Coordinator stated the admission record showed bipolar disorder and that the PASRR screening should have been resubmitted to reflect that diagnosis, but it was not. Resident 10 was admitted with diagnoses including respiratory failure with hypoxia, type 2 diabetes mellitus, and unspecified psychosis not due to a substance or known physiological condition. The H&P indicated the resident could make needs known but could not make medical decisions. The PASRR Level I screening dated at admission stated the resident did not have a serious diagnosed mental disorder, no suspected mental illness, and had not been prescribed psychotropic medications. The Subacute Coordinator stated the admission record showed unspecified psychosis and that the PASRR screening should have been resubmitted to reflect that diagnosis, but it was not. Resident 3 was originally admitted and later readmitted with diagnoses including PTSD, unspecified psychosis not due to a substance or known physiological condition, and other psychoactive substance abuse. The H&P indicated the resident had the capacity to understand and make decisions, while the MDS indicated moderate cognitive impairment and need for assistance with mobility, transfers, dressing, toileting, and personal hygiene. The MAR showed orders for Zoloft for depression and Seroquel for psychosis. The PASRR Level I screening stated the resident did not have a serious diagnosed mental disorder, no suspected mental illness, and had not been prescribed psychotropic medications. The Subacute Coordinator stated the resident’s diagnosis and medications showed SMI and that the PASRR screening should have been resubmitted, but it was not.
Missing Care Plans for Residents With Schizophrenia and Bipolar Disorder
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents with mental health diagnoses. Resident 11 was admitted from another LTC facility with diagnoses including chronic respiratory failure, tracheostomy, and paranoid schizophrenia. The resident’s H&P documented schizophrenia and indicated the resident had the capacity to understand and make decisions. The MDS also identified schizophrenia and noted the resident was not taking any antipsychotic medications, yet no care plan was developed and implemented to address the schizophrenia. Resident 4 was admitted from an acute hospital with diagnoses including respiratory failure, tracheostomy, and bipolar disorder. The resident’s H&P documented bipolar disorder and stated the resident did not have the capacity to understand and make decisions. The MDS identified bipolar disorder and noted the resident was not taking any antipsychotic medications, yet no care plan was developed and implemented to address the bipolar disorder. During interviews with the MDSC and SAC, both staff members confirmed that neither resident had a care plan addressing the documented mental health diagnosis. They stated that baseline care plans are initiated within 48 hours of admission and comprehensive care plans are developed and implemented within 7 days after completion of the admission MDS assessment or within 21 days of admission. They also stated that the MDS assistant, MDSC, SAC, and licensed nurses are responsible for ensuring care plans are developed, implemented, and reviewed. The facility policy stated that comprehensive person-centered care plans must include measurable objectives and timetables and address the resident’s physical, psychosocial, and functional needs.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
Licensed nursing staff failed to provide insulin administration in accordance with professional standards for two sampled residents by not rotating subcutaneous injection sites as ordered. For Resident 7, the record showed diagnoses including type 2 DM, long-term insulin use, a foot ulcer, and alcoholic cirrhosis of the liver. The resident’s orders included Novolog FlexPen before meals and at bedtime and insulin glargine daily, both with instructions to rotate injection sites. The care plan also directed staff to rotate sites for insulin injections. The Location of Administration Report for Resident 7 showed repeated use of the same abdominal site for insulin glargine on multiple dates and repeated use of the same abdominal site for Novolog on multiple administrations. During the concurrent interview and record review, the ADON stated that not rotating insulin administration sites is a medication error, that staff failed to rotate sites as shown on the report, and that rotation is used to prevent skin damage and avoid lipodystrophy and insulin malabsorption. For Resident 90, the record showed diagnoses including type 2 DM with proliferative diabetic retinopathy and ESRD. The resident had orders for insulin lispro before meals and at bedtime and insulin glargine-yfgn at bedtime, both with instructions to rotate injection sites, and the care plan also directed staff to rotate insulin sites. The Location of Administration Report showed repeated insulin lispro administration in the same abdominal area on two occasions and repeated use of the left arm on two occasions. During the interview and record review, the ADON again stated that failure to rotate insulin sites is a medication error and that staff failed to rotate the sites as documented.
Catheter tubing loops and unlabeled urinal observed
Penalty
Summary
Appropriate care was not provided for residents with urinary catheters and for one resident using a urinal. Resident 111 was admitted and later readmitted with diagnoses including UTI, C. difficile enterocolitis, and MRSA infection. The resident’s record showed a suprapubic catheter order and a care plan directing staff to keep the catheter bag and tubing below bladder level, check for kinks each shift, and provide suprapubic care. During observation, Resident 111’s suprapubic catheter tubing was looped at the side of the bed, and urine was trapped in the loops and not draining into the collection bag. The RNA stated the tubing should not have loops to prevent backflow of urine into the bladder or growth of bacteria on the tubing where urine settles. Resident 113 was admitted with diagnoses including acute and chronic respiratory failure, tracheostomy, and neuromuscular dysfunction of the bladder. The resident’s record showed severe cognitive impairment, total dependence for ADLs, and an indwelling urinary catheter order with Foley catheter care every shift. During observation, Resident 113 was lying in bed with the bedside drainage bag hanging on the side of the bed frame and the catheter tubing forming a dependent loop. The LVN stated the loop prevented urine from flowing freely and that urine was present in the loop with some white sediment. The SAC and DON stated the tubing should not be coiled or kinked because urine should flow freely and not backflow into the bladder. Resident 17 was admitted with diagnoses including hepatic encephalopathy, COPD, and heart failure. The resident’s record indicated the resident was awake, alert, oriented, cooperative, able to follow commands, and had normal cognitive function. During observation, the urinal for Resident 17 did not have the resident’s name, room number, initials, or date. The CNA stated the unlabeled urinal could be confused with another resident’s urinal and could also get an infection. The ADON stated urinals should be labeled with the resident’s initials and the date it was provided, and the facility policy indicated resident names should be written on appropriate articles such as a urinal.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors related to insulin administration for two sampled residents. For Resident 7, the record showed diagnoses including type 2 diabetes mellitus, long-term insulin use, and alcoholic cirrhosis of the liver. The resident’s orders included Novolog FlexPen and insulin glargine, both with instructions to rotate injection sites. The care plan also directed staff to rotate insulin injection sites. The Location of Administration Report for Resident 7 showed repeated insulin injections in the same abdominal area. Insulin glargine was documented multiple times in the left lower quadrant of the abdomen, and Novolog was documented in the right upper quadrant of the abdomen and then twice in the left lower quadrant on the same date. During interview and record review, the ADON stated that not rotating insulin administration sites is a medication error and confirmed that staff failed to rotate the sites as shown on the record. The ADON stated rotation is used to prevent skin damage and that frequent use of the same site can lead to lipodystrophy and malabsorption of insulin. For Resident 90, the record showed diagnoses including type 2 diabetes mellitus with proliferative diabetic retinopathy and end stage renal disease. The resident had orders for insulin lispro and insulin glargine-yfgn, both with instructions to rotate injection sites, and the care plan also directed staff to rotate insulin injection sites. The Location of Administration Report showed insulin lispro given in the left lower quadrant of the abdomen on two occasions and then in the left arm on two occasions. During the same interview and record review, the ADON again stated that failing to rotate insulin administration sites is a medication error and confirmed staff failed to rotate the injection sites as documented.
Food Service Staff Competency and Sanitation Failures
Penalty
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills related to food safety and sanitation. During observation, Cook 1 prepared seas green peas and did not take the temperature of the food while cooking. In interviews, Cook 1 first stated she checked food temperatures during cooking and before trayline, then later stated she had misspoken and that she did not use a thermometer to check the vegetables while cooking. The Dietary Supervisor stated the facility did not record cooking temperatures of foods, while the Registered Dietitian stated cooks were expected to take food temperatures during cooking and that it was not appropriate to rely on visual judgment alone. The report also documented improper handling of a blender used for puree foods. A Dietary Aide washed the blender in a two-compartment sink and did not completely dry it before it was used again. The blender was then used to puree meat sauce and later spaghetti noodles while liquid was still dripping from it. The Cook stated the blender had to be air dried after sanitizing and that visible water dripping could contaminate food, but also stated she did not check whether the blender was dry before using it. Facility policies and Food Code references in the report required equipment and utensils to be air-dried after cleaning and sanitizing. In a separate observation, Dietary Aide 2 used the wrong test strips when checking sanitizer concentration. The Dietary Supervisor observed that the aide used QUAT test strips while checking chlorine sanitizer and then provided the correct test strips. The Dietary Supervisor stated the correct test strips were needed to ensure the proper sanitizer concentration. The Dietary Aide job descriptions and competency checklists reviewed in the report did not show competency for using the correct test strip to test chlorine concentration, and the checklist for the Cook did not show competency for the internal minimum temperature of food when cooking.
Late Lunch Meal Service
Penalty
Summary
The facility failed to provide residents' meals at the regular scheduled time in accordance with resident needs, preferences, and requests when lunch was served late on 3/23/2026. A posted meal schedule in the hallway showed breakfast at 7:00 a.m., lunch at 12:00 p.m., and dinner at 5:00 p.m. During observation of the trayline at 11:48 a.m., a Dietary Aide was taking temperatures of pureed foods, and the Registered Dietitian corrected the aide on how to hold the thermometer. The pureed green peas were 130 F and the pureed meat sauce was 126 F, both below the facility standard of 165 F, and both items were placed back in the oven. At 12:22 p.m., trayline service had still not started, and the Dietary Supervisor stated the trayline was late because the food temperatures could not be met. The first cart did not come out of the kitchen until 12:30 p.m. The Dietary Supervisor stated lunch was scheduled for 12 noon and that it was important for meals to be served on time so residents would not get too hungry and would have the same time between each meal; the supervisor also stated residents could be agitated when hungry. The facility policy titled Meal Service Time, dated 9/10/2025, stated each resident would receive at least three meals daily and offered a bedtime snack, with established mealtimes of breakfast at 7 a.m., lunch at 12 p.m., dinner at 5 p.m., and snacks at 10 a.m., 2 p.m., and 8 p.m.
Unsafe Food Storage and Preparation Practices
Penalty
Summary
The kitchen failed to maintain safe and sanitary food storage and preparation practices during multiple observed events. Ground beef that had thawed was placed back into the freezer and was soft to the touch at the time of observation. The Dietary Supervisor stated the meat had been received the prior Sunday, had thawed, and should not have been returned to the freezer because bacteria could begin growing during thawing and refreezing could contribute to foodborne illness. The facility’s thawing policy stated that once thawed raw food will not be refrozen unless it is thoroughly cooked. The walk-in refrigerator had a torn gasket with dust and dirt buildup, and two dented cans were stored with non-dented cans in dry storage. The Dietary Supervisor stated the gasket should not be torn because hot air could enter and spoil food, and that dented cans should be separated because air could enter the cans and bacteria could grow. The report also noted a sugar-free watermelon drink with a best buy date of 3/23/2026 that was still present the next day, and a residents’ refrigerator in Station 1 that had visible dirt debris. In Station 1, an unlabeled bottle of Powerade was stored in the residents’ refrigerator inside the medication storage room without a name, room number, or received date. Food preparation and sanitation practices were also not followed during cooking and warewashing. A cook did not take the temperature of vegetables while cooking and instead relied on visual judgment. A dietary aide washed a blender but did not completely air dry it before it was used to prepare puree foods, did not fully submerge it in QUAT sanitizer for the required time, and handed it over while it was still dripping. Kitchen staff also failed to perform proper hand hygiene when moving from dirty to clean tasks, including washing hands for only a few seconds, using a blue towel to dry hands, and turning off the faucet with bare hands. Additional observations showed a tortilla being toasted directly on the stove without sanitizing the surface first, dust buildup on the wall AC vent in the preparation area, the wrong test strips being used to check chlorine concentration of the dish machine, and no thermometer in the freezer where egg waffles were stored.
Arbitration Agreement Missing Required Communication Language
Penalty
Summary
The facility failed to ensure its binding arbitration agreement included language stating that the resident or anyone else, including a resident representative, was allowed to communicate with federal, state, or local officials, including federal and state surveyors, other health department employees, and representatives of the Office of the State Long Term Care Ombudsman. This omission was identified for three of three sampled residents reviewed for the Arbitration Facility Task: Residents 33, 75, and 93. Resident 33 was admitted with diagnoses including major depressive disorder and anxiety disorder. The resident’s H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated the resident had impaired cognition but could make self-understood and understand others, with a family member participating in assessment and goal setting. Resident 33 electronically signed the arbitration agreement, but the agreement did not contain the required communication language. Resident 75 was admitted and later readmitted with diagnoses including depression and systolic heart failure. The H&P stated the resident had capacity to understand and make decisions, and the MDS indicated intact cognition. Resident 93 was admitted and later readmitted with diagnoses including acute embolism, thrombosis of deep veins in the lower extremity bilaterally, and diverticulitis of the intestine; the H&P stated the resident had capacity to understand and make decisions. Both residents also signed arbitration agreements that did not include the language allowing communication with the listed officials. During interviews, the Admissions Coordinator and Administrator stated the language was not on the facility’s arbitration agreement and agreed it should be included so residents know they can communicate with those entities. The facility’s policy on Arbitration stated the agreement may not contain language that prohibits or discourages such communications.
Infection Control Program Deficiencies in Hand Hygiene, Linen Cart Coverage, Water Temperature, and Glucometer Disinfection
Penalty
Summary
The facility failed to maintain its infection prevention and control program in several observed situations. During a concurrent observation and interview, a CNA changed a resident’s adult brief and removed the resident’s gown and gloves without performing hand hygiene after glove removal. The resident had been admitted with diagnoses including a right femur fracture, DM, hypothyroidism, anxiety, hypertension, and a history of falling. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated moderately impaired cognitive skills for daily decision making and need for staff assistance with oral care, toileting, personal hygiene, and shoes. In the laundry area, linen carts for residents’ personal clothing were observed covered with blue woven/permeable material rather than a loosely woven/permeable cover that would protect the linens inside the cart. Laundry personnel stated the carts for personal clothing had always been covered that way, and the Maintenance Supervisor and ADON stated the mesh or permeable covering allowed air and water to seep through and did not fully protect the clothing from environmental contamination. The facility’s laundry and linen policy stated clean linen should remain hygienically clean through measures designed to protect it from environmental contamination, such as covering clean linen carts. The facility’s water temperature log showed multiple room temperatures at 106 to 108 degrees F across January through March. During interview, the MS and IP stated the facility was following the CDC Legionella water management toolkit and that water temperature control was being used to prevent growth of water-borne bacteria. They stated the temperature range where Legionella grows best is 77 to 108 degrees F, and the DON stated that when water temperature falls within the range where bacteria grow best, there is a risk for bacteria going into the facility’s water system that could potentially cause illness among residents. During medication administration, an LVN removed a glucometer from the medication cart, disinfected it with an alcohol swab in one sweeping motion from front to back, used it for a resident with severe cognitive impairment, tracheostomy, and total dependence for ADLs, and then again wiped the glucometer in one sweeping motion after use. The resident was on enhanced barrier precautions, and the subacute unit residents were described as all having tracheostomies and being at risk for acquiring infection if shared resident care equipment was not disinfected properly. The SAC stated the glucometer should have been wiped all over, including the sides, front, back, and the area where the test strip was inserted. The facility’s policies stated hand hygiene is required immediately after glove removal, clean linen carts should be covered to protect against contamination, and reusable blood glucose meters must be cleaned and disinfected between resident uses according to manufacturer instructions and infection control standards.
Flies Observed in Dishroom During Food Service Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department when five flies were observed in the dishroom during a concurrent observation and interview with the Dietary Supervisor. The flies were seen flying and landing from dirty dishes, to trash, and then to clean dishes. The Dietary Supervisor stated that flies were present in the dishwashing area and did not know why, although the pest control company had come in that morning. During a later interview, the Dietary Supervisor stated that flies were landing on clean dishes and that the area needed to be fly free to keep clean dishes away from the flies. A review of the facility's Pest Control policy, dated 9/10/2025, stated that the facility shall maintain an effective pest control program and maintain an on-going pest control program to ensure that the building.
Failure to Timely Report and Act on Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of staff-to-resident abuse to the Administrator, the State Survey Agency (CDPH), the Ombudsman, and local law enforcement within the required two-hour timeframe. The involved resident, identified as Resident 20, had multiple diagnoses including type 2 diabetes mellitus, legal blindness, and adult failure to thrive, and was assessed as having severely impaired cognition. According to the Minimum Data Set, the resident required extensive assistance with most activities of daily living. The History and Physical indicated that the resident had the capacity to understand and make decisions. On the early morning in question, at approximately 4:30 a.m., Certified Nursing Assistant (CNA) 6 was providing ADL care to Resident 20 when the resident accused CNA 6 of hitting her during care and continued to scream and repeat the accusation. CNA 6 acknowledged that such an accusation should be considered an allegation of abuse but did not report it to the charge nurse because she believed she had not hit the resident. CNA 6 continued providing care, then left to care for another resident without notifying supervisory staff. CNA 5, who was caring for the resident’s roommate, later observed Resident 20 upset and crying and heard her state in Spanish that CNA 6 was very rough with her. CNA 5 then informed Licensed Vocational Nurse (LVN) 8 that the resident was upset and requested that LVN 8 speak with the resident. LVN 8 went to the room, found Resident 20 upset, and heard the resident state that she had been hit by a CNA, but LVN 8 did not ask the resident to identify which CNA was involved. LVN 8 checked the resident for injuries, found none, and then resumed medication administration without reporting the allegation to the Administrator or Director of Nursing and without removing the alleged perpetrator from the assignment. Later that morning, the Assistant Director of Nursing (ADON) was informed by the nurse assigned to Resident 20 that the roommate reported hearing a slapping sound while Resident 20 was receiving care and that Resident 20 said she had been hit on the face by CNA 6. The ADON confirmed through interviews with CNA 5, CNA 6, and LVN 8 that the allegation occurred between approximately 4:30 a.m. and 5:00 a.m. The Administrator was not made aware of the allegation until about 9:15 a.m., at which time she learned that CNA 6 had not reported the allegation, CNA 5 had only reported to LVN 8, and LVN 8 had not escalated the allegation. The facility’s abuse policy required that any suspicion or allegation of abuse be reported immediately to the Administrator and to CDPH, the Ombudsman, and law enforcement within two hours, and that any employee accused of abuse be removed from resident contact until the investigation was complete; these requirements were not followed in this incident. The Director of Staff Development, ADON, and Administrator each confirmed during interviews that all staff are mandated reporters and that any allegation of abuse, regardless of perceived validity, must be reported immediately to the Administrator so that external reporting can occur within two hours. They also confirmed that the accused staff member should be removed from the assignment and from resident contact pending investigation. In this case, CNA 6 did not report the allegation to the nurse, CNA 5 did not report directly to the Administrator, and LVN 8 did not notify the Administrator or remove CNA 6 from caring for the resident. As a result, the facility did not follow its own policy and regulatory requirements for timely reporting of an abuse allegation involving Resident 20.
Incomplete informed consent for bilateral bolsters
Penalty
Summary
The facility failed to honor a resident’s right to be informed in advance of the risks, benefits, and alternatives of proposed care by not completing the informed consent for bilateral bolsters in bed. Resident 73 was admitted and later readmitted with chronic respiratory failure, a tracheostomy, and quadriplegia. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition, inability to understand and make needs known, impairment of both upper and lower extremities, and total dependence on staff for all ADLs. The physician’s order specified bilateral bolsters in bed for comfort, positioning, and safety, and the informed consent documented a phone consent from the responsible party. However, the consent did not state the reason for use of the bolsters. During interview and record review, the SAC stated the bolsters were strapped to the bedframe and used for resident safety and positioning, and acknowledged the consent should have included the reason for the device so the resident or representative could make an informed decision. The facility policy required consent to include the specific reason for the restraint, how it would benefit the resident’s medical symptom, the type of restraint, and the period of use.
Dilapidated Bedside Drawer in Resident Room
Penalty
Summary
The facility failed to honor Resident 84’s right to a safe, clean, comfortable, and homelike environment by allowing a dilapidated bedside drawer to remain in the resident’s room. Resident 84 was admitted on 11/25/2025 with diagnoses including major depressive disorder, anxiety disorder, and age-related physical debility. The resident’s H&P dated 11/26/2025 indicated impaired mental status, that the resident did not follow commands, and that the resident did not have the capacity to understand and make decisions. During a concurrent observation and interview on 3/23/2026, the DON observed Resident 84’s bedside drawer in a dilapidated condition with multiple tapes holding it together. The drawer was not properly maintained and, when pulled out, could fall apart into pieces. The DON stated the drawer could fall off and hurt the resident and was not promoting a homelike environment. During a later interview, the ADON stated it was not appropriate to have broken furniture in the resident’s environment because it did not promote a homelike environment, and that the facility’s Homelike Environment policy was not followed.
Failure to Document and Provide Transfer Report During Resident Discharge
Penalty
Summary
The facility failed to follow its policy and procedure for discharging a resident to another facility by not ensuring that necessary medical information was communicated to the receiving SNF for one resident. The resident was admitted with diagnoses including dementia, difficulty walking, and heart failure. The resident's H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated moderately impaired cognition, ability to understand others and make needs known, and varying levels of assistance with ADLs. The resident had a physician's order to discharge to SNF 1, and social services notes documented that the resident representative requested the transfer to that facility. The discharge summary noted that the resident was discharged to SNF 1 per family request and that the physician was notified of the discharge, but it did not indicate that a verbal report was provided to SNF 1 before the transfer. The discharge instruction form/recapitulation of stay also did not identify the next provider, provider type, or that a verbal report was provided to SNF 1. During interview and record review, RN 2 stated that the discharging nurse is responsible for calling the receiving facility for a report and documenting that report in the medical record, and that she was the nurse who discharged the resident but did not document calling SNF 1. The ADON stated that the discharging nurse must call the receiving facility to provide report on the resident's current status, including functioning, isolation status, and medications, and must complete the discharge instruction form to include the next provider and provider type. The facility's policy stated that when a resident is discharged to another facility, a transfer summary and telephone report to the receiving facility are required, and the date and time of discharge must be recorded in the medical record.
Medication Left at Bedside
Penalty
Summary
The facility failed to ensure a resident’s environment was free of accident hazards when a bottle of Refresh eye drops was left on top of the resident’s side table. The resident was admitted with diagnoses including dependence on renal dialysis, ESRD, and peritoneal abscess. The history and physical indicated the resident had the capacity to understand and make decisions, while the MDS showed the resident had moderate cognitive impairment and was dependent to needing supervision for mobility and ADLs. The resident’s order summary included an order for Refresh Tears Ophthalmic Solution, one drop in both eyes every four hours as needed for dry eyes. During observation in the resident’s room, the Hemodialysis Supervisor saw the bottle of eye drops left at the bedside. The supervisor stated there should be no medications left at the bedside for the resident’s safety. During interview and record review, the ADON reviewed the resident’s order summary and stated the resident did not have an assessment for self-administration of medication and it was not appropriate to leave medication at the bedside. The ADON stated licensed nurses keep medications inside the medication cart and provide them when needed, and acknowledged staff failed to keep the eye drops away from the resident by leaving them at the bedside. The ADON also stated the policy and procedure for Storage of Medications and Safety and Supervision of Residents were not followed.
Tube Feeding Water Flush Bags Not Changed per Manufacturer Guidance
Penalty
Summary
The facility failed to ensure that enteral feeding residents received appropriate care and services when the water flush bags for two residents with gastrostomy tubes were not changed according to the manufacturer’s recommendations. Resident 119 was admitted with diagnoses including acute respiratory failure with hypoxia, tracheostomy, and gastrostomy, and the record showed tube feeding and free water flush orders. Resident 43 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, tracheostomy, and gastrostomy, and the record also showed tube feeding and free water flush orders. Both residents were receiving continuous tube feeding through GTs and had care plans directing staff to administer the ordered tube feeding and free water flushes. During observation of both residents in their rooms, the water flush bags were noted to have a date and time indicating they had been hung on the same prior date and time. In interviews, LVN 3 stated the date and time on the tube feeding and water flush bags reflected when the bags were hung, and that the facility’s process was to change the water flush bag when the feeding bag finished. LVN 3 also stated she was not aware that the water flush could not be used for more than 24 hours. During interview and record review, the SAC reviewed the physician orders and the manufacturer’s guideline for the water flush bag. The SAC stated the facility did not follow the manufacturer’s recommendation that the feeding set not be used for more than 24 hours. The facility policy referenced hang times and administration set changes, and the manufacturer’s guideline stated that due to the risk of bacterial contamination and overall system accuracy, feeding sets should not be used for greater than 24 hours.
Respiratory Equipment and Sterile Water Not Discarded per Policy
Penalty
Summary
Resident 111 was admitted and later readmitted with diagnoses including acute respiratory failure with hypoxia and abnormalities of breathing. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, while the MDS dated 3/12/2026 indicated the resident had the ability to make self-understood and understand others and had intact cognition. The OSR dated 3/23/2026 included an order for oxygen at 2-3 L/min via nasal cannula as needed for shortness of breath/asthma. During a concurrent observation and interview on 3/23/2026, surveyors observed Resident 111’s oxygen tubing via nasal cannula placed inside a plastic bag and dated 3/12/2026. The RNA stated the nasal cannula tubing should have been changed the prior week to prevent buildup of bacteria on the tubing that can cause a resident to get sick. During a later interview and record review, the ADON stated the oxygen via nasal cannula setup should have been discarded and replaced with a new setup to prevent respiratory infection, and stated the oxygen tubing should be changed weekly. The ADON also stated the facility’s policy titled Departmental (Respiratory Therapy) - Prevention of Infection was not followed. Resident 90 was admitted with diagnoses including COPD, obstructive sleep apnea, and chronic diastolic heart failure. The H&P stated the resident had the capacity to understand and make decisions, and the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment; the MDS also indicated the resident had a non-invasive mechanical ventilator. During observation on 3/23/2026, surveyors found a 1000 ml bottle of sterile water for inhalation in the resident’s room with an opened date of 3/1/2026. The HDS stated he did not know when opened bottles should be discarded. LVN 1 stated the bottle should be discarded within 24 hours when opened and that it was single-patient use. The ADON later stated the bottle was for one-time use and should have been discarded, and stated the facility’s respiratory infection prevention policy was not followed.
Expired Medications Found and Insulin Dose Verification Not Completed Before Preparation
Penalty
Summary
Expired medications were found in the Medication Storage Room for Station 1 during observation and interview. A bottle of Major Co q-10 50 mg soft gels house supply was observed with an expiration date of 1/2026. RN 1 stated the bottle was expired and said she did not know how frequently licensed nurses checked for expired medications in the Medication Storage Room, although she believed Central Supply checked weekly. The ADON later stated the licensed staff should have discarded the expired bottle and that RN Supervisors and licensed nurses were supposed to check medication stocks in the Medication Storage Room daily and every time they accessed medications. An insulin lispro Kwik pen in Station 1, Cart 1 was also observed with an open date of 2/6/2026 and was not discarded even though staff stated it was only good for 28 days once opened. During the medication storage and labeling task, LVN 2 identified the pen as expired because it had been open beyond the allowed time. The ADON confirmed that the insulin pen should have been discarded because it was only good for 28 days after opening and stated that keeping the expired pen had the potential to cause hypo- or hyperglycemia. During medication administration for a resident with DM 2, the LVN gathered supplies, checked the resident’s blood sugar, and prepared to administer insulin lispro. The resident had diagnoses including DM 2 and ESRD, and the record showed the resident had intact cognition and could understand and make decisions. The LVN attached the needle and stated the resident would receive 4 units based on the sliding scale, but she did not check the eMAR before setting the dose and said she was relying on memory. She later checked the eMAR after beginning the dose-setting process and acknowledged she should have reviewed the eMAR first to ensure the resident received the correct amount of insulin. The SAC also stated the eMAR should have been checked before setting the dose on the insulin pen.
Medication Cart Labeling Deficiencies
Penalty
Summary
Drugs and biologicals in two medication carts were not labeled in accordance with accepted professional principles. In Station 1, Cart 1, a bottle of Refreshe eye drops was observed with an unreadable room number, no resident name, and no open date. During the observation and interview, the LVN stated the bottle should have the resident’s name, room number, and open date so the medication is given to the correct resident and is not expired. The ADON later stated the bottle should have been discarded because it had no name, unreadable room number, and no open date, and that opened eye drops are only good for 28 days. In Station 1, Cart 2, a bottle of Potassium Citrate-Citric Acid for Resident 87 was observed without an open date and was less than half empty. Resident 87’s record showed diagnoses including aphasia following cerebral infarction, dysphagia following cerebral infarction, and calculus of kidney, and the MDS indicated severe cognitive impairment and extensive assistance needs. The LVN stated the medication should have had an open date because staff could not tell whether it was expired without one. The ADON stated multidose medication bottles should have an open date because without it staff may not know if the medication is expired. The facility policy stated medication labels should include the resident’s name and expiration date when applicable, and opened multi-dose vials should be dated and discarded within 28 days unless otherwise specified.
Failure to Clarify Continued Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship and infection prevention and control program for one sampled resident by not clarifying with the physician the appropriate indication for continued use of an antibiotic started in the hospital. Resident 119 was admitted with diagnoses including acute respiratory failure with hypoxia, tracheostomy, and acute serious otitis media. The resident’s H&P stated she was able to make her needs known but could not make medical decisions, and the MDS indicated severely impaired cognition, though she was usually able to understand and make her needs known. The MDS also showed she required substantial to maximal assistance with oral hygiene and was totally dependent on staff for all other ADLs, and that she received antibiotics. On admission, the physician ordered amoxicillin-pot clavulanate 875-125 mg via GT twice daily for otitis media for 6 days. The care plan for otitis media, initiated the next day, included administering the antibiotic as ordered so the resident would be free from complications related to infection. The Antibiotic Time Out form later documented that the resident did not have a fever, had no trending changes in respirations, pulse, or blood pressure, and had no signs or symptoms of infection. The form also documented that the physician was notified of the current antibiotic order and stated to continue the antibiotic therapy. During interviews, the Infection Preventionist stated that based on the Antibiotic Time Out form, the resident did not meet criteria for continuation of the antibiotic and that if the physician said to continue, she was supposed to ask for the appropriate indication for continued use from the hospital. She stated she discussed with the physician that the resident did not meet criteria, but she did not ask for the appropriate indication for continued use. The Subacute Coordinator similarly stated the resident did not meet criteria for continuation and that the Antibiotic Time Out form did not indicate the appropriate indication for continued use. The facility policy stated antibiotics were to be prescribed and administered under the guidance of the antibiotic stewardship program, whose purpose was to monitor antibiotic use in residents.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to implement its Pneumococcal Vaccine policy and procedure for one sampled resident by not administering the pneumonia vaccine. Resident 3 was originally admitted on 4/28/2025 and later readmitted, with diagnoses including PTSD, unspecified psychosis, other psychoactive substance abuse, dysphagia, acute kidney failure, and a history of colon cancer. The resident’s H&P dated 8/30/2025 noted a past medical history of acute respiratory failure status post tracheostomy and that the resident had the capacity to understand and make decisions. The MDS dated 8/30/2025 indicated the resident was able to make needs known and understand others, and was dependent for oral hygiene, toileting hygiene, personal hygiene, showers, and upper and lower body dressing. During interview and record review, the IP Nurse reviewed the resident’s immunization report and stated the resident had Pneumovax Dose 1 with historical status dated 5/14/2018 and Pneumovax Dose 2 with historical status dated 6/24/2019. The IP Nurse stated the pneumococcal vaccine should have been given after five years and that, based on the Pneumorecs VaxAdvisor App, the resident should have been offered or given the pneumonia vaccine. The IP Nurse also stated there was no documentation that the resident refused the pneumococcal vaccine. The DON stated that pneumonia vaccine is offered upon admission and that residents who have not received a pneumonia vaccine may be at risk for respiratory problems, especially among older adults. The facility’s policy stated that residents are assessed for eligibility prior to or upon admission and offered the pneumococcal vaccine series within 30 days unless medically contraindicated, already completed, or refused.
Failure to Notify Physician and Responsible Party of Discontinuation of LAL Mattress
Penalty
Summary
The deficiency involves the facility’s failure to notify the attending physician and the resident’s responsible party of a significant change in treatment when a low air loss (LAL) mattress was discontinued for a resident at high risk for pressure ulcers. The resident had been admitted and later readmitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, type 2 DM, and HTN. The care plan, initiated and later revised, identified the resident as at risk for unavoidable pressure ulcers related to immobility and included an intervention that the resident may have an LAL mattress for wound and skin management. An IDT wound management update documented that a lower back ulcer had resolved but still recommended an LAL mattress and off-loading. The resident’s MDS showed the resident was unable to understand and be understood and was dependent for most ADLs, and a Braden Scale assessment scored the resident at 11, indicating high risk for pressure ulcer development. On a subsequent date, the order summary report showed an active order for an LAL mattress for wound and skin management that was discontinued with the notation that the resident’s skin was intact. There was no documentation that the physician or the responsible party were notified of this change in treatment at the time the order was discontinued. Social services documentation later recorded that a family member complained that the mattress had been removed and questioned whether there was a physician’s order to remove it. The treatment nurse told the family member that no physician order was necessary because the resident did not have wounds and that the LAL mattress was not needed. The treatment nurse also stated in interview that the LAL mattress had been removed about a week earlier based on direction from the DON to discontinue LAL mattresses for residents without pressure ulcers and that neither the physician nor the family were notified because the facility followed a protocol and there was no perceived change in condition. During interview and concurrent record review, the DON acknowledged that, based on the Braden assessment, the resident needed the LAL mattress even without an active pressure ulcer and that an order was required both to initiate and discontinue the LAL mattress. The DON stated that if the treatment nurse did not notify the physician, there was an issue, and confirmed that this should have been considered a change in treatment requiring physician notification. The DON further stated that the family had the right to know when there is a change in treatment and that the responsible party should have been notified on the date the order was discontinued, and that failure to notify the resident representative of the change in treatment was a violation of the resident’s and representative’s right to know and make decisions. Facility policies on change in condition and support surface guidelines required prompt notification of the physician and resident representative when medical treatment is significantly altered and the use of appropriate support surfaces for individuals at risk for pressure ulcers.
Failure to Follow Antihypertensive Hold Parameters
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for holding antihypertensive medications for one resident. The resident was admitted with diagnoses including an unspecified thoracic vertebra wedge compression fracture, essential hypertension, and generalized muscle weakness. The physician’s orders, dated 12/3/2025, directed that atenolol 50 mg by mouth daily be held if systolic blood pressure (SBP) was less than 110 mmHg or pulse was less than 60 bpm, and that losartan 100 mg by mouth daily be held if SBP was less than 110 mmHg. The resident’s History and Physical indicated the resident had capacity to understand and make decisions, while the MDS dated 12/5/2025 documented severely impaired cognitive skills for daily decisions and dependence on staff for toileting, showering, and dressing. Review of the Medication Administration Record for 12/2025 showed that LVN 1 documented administration of atenolol and losartan on multiple dates when the resident’s SBP was below the 110 mmHg hold parameter. Specifically, atenolol and losartan were documented as given on 12/25/2025 at 9 a.m. with a BP of 109/70 mmHg, losartan was documented as given on 12/26/2025 at 9 a.m. with BP 108/72 mmHg, on 12/27/2025 at 9 a.m. with BP 106/68 mmHg, and on 12/28/2025 at 9 a.m. with BP 109/70 mmHg, and atenolol again on 12/28/2025 at 9 a.m. with BP 109/72 mmHg. During interview, LVN 1 stated that a check mark on the MAR indicated the medication was administered and claimed he had actually held the atenolol and losartan on those dates and times but could not prove this. RN 1 and the DON both stated that LVN 1 should have followed the physician’s orders and held the medications when SBP was below 110 mmHg, and the facility’s medication administration policy required medications to be administered as prescribed, including verification of vital signs when necessary.
Failure to Develop Person-Centered Care Plan for Antibiotic Therapy
Penalty
Summary
Surveyors identified a failure to develop and implement a person-centered care plan addressing the use of specific antibiotics for one resident. The resident was admitted with diagnoses including an unspecified thoracic vertebra wedge compression fracture, essential hypertension, and generalized muscle weakness. A History and Physical dated 12/5/2025 documented that the resident had capacity to understand and make decisions, while the MDS from the same date indicated severely impaired cognitive skills for daily decisions and dependence on staff for toileting, showering, and dressing. On 12/11/2025, the physician ordered cephalexin 500 mg twice daily for seven days for a UTI, following a complaint of urinary discomfort on 12/10/2025 and subsequent urinalysis results. The Medication Administration Record showed the resident received cephalexin from 12/11/2025 at 5 p.m. through 12/14/2025 at 5 p.m. A care plan dated 12/11/2025 and revised on 12/26/2025 addressed a history of UTI with general interventions to administer medications as ordered and monitor for side effects, but it did not identify or individualize care for the specific antibiotic therapy. On 12/14/2025, the physician ordered ciprofloxacin 500 mg twice daily for seven days for UTI, and the MAR showed the resident received ciprofloxacin from 12/15/2025 at 9 a.m. through 12/21/2025 at 5 p.m. During interviews and record reviews, the Infection Preventionist stated that residents on antibiotics such as cephalexin and ciprofloxacin are to be monitored every shift for signs and symptoms of infection and adverse reactions, with documentation in progress notes, and that a care plan for antibiotic use should be developed on the day antibiotics start and revised with any change in antibiotic medication. The IP confirmed there was no care plan developed for the resident’s use of cephalexin and ciprofloxacin and noted that without an updated or revised care plan, nurses might miss interventions and potentially delay care. The DON stated that nurses should update the care plan based on monitoring of the antibiotic and that the resident’s care plan should be person-centered and revised as the resident’s condition changes, consistent with the facility’s Comprehensive Person-Centered Care Plans policy, which requires measurable objectives, timeframes, and revisions as conditions change. RN 1 acknowledged that the facility updates care plans with general interventions and stated there was no direct effect on the resident if the antibiotic care plan was not revised.
Failure to Timely Notify Wound Care Physician of Existing Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with multiple pressure ulcers received care consistent with professional standards by not timely notifying the Wound Care Physician (WCP) of the resident’s wounds. The resident was admitted with diagnoses including a thoracic vertebra wedge compression fracture, essential hypertension, and pressure-induced deep tissue damage of the left heel and other sites. On admission, the resident’s assessment documented multiple pressure ulcers on the right deltoid, right lateral forearm, right lateral knee, and right upper and lower hip, and the admission orders included daily betadine and dry dressings to several of these areas. The facility’s policy required that practitioners assist in identifying ulcer type, characteristics, complications, and contributing factors. Subsequent documentation showed that the resident’s H&P identified pressure ulcers on the right shoulder, right rib area, right upper and lower hip, right elbow, and right lateral leg, and the MDS indicated the resident had severely impaired cognitive skills for daily decisions, was dependent on staff for ADLs such as toileting, showering, and dressing, and was at risk for pressure ulcers with four unstageable pressure ulcers and one DTI present on admission. Interdisciplinary Wound Management Updates on two separate dates documented “wound consult,” indicating that a wound consult was needed. However, interviews revealed that the Treatment Nurse was responsible for wound care consult orders and that the practice was to notify the WCP of wounds only when the WCP visited weekly, not on the day of admission. The WCP visited the facility on two occasions after the resident’s admission but was not informed of the resident’s pressure ulcers on those visits. The DON confirmed that the WCP stated no one had informed him of the resident’s pressure ulcers during his earlier visit. The Treatment Nurse stated that the WCP was not informed on the first two weekly visits after admission and that the WCP did not see the resident for 12 days after admission. When the WCP finally evaluated the resident, multiple pressure ulcers were assessed and a surgical debridement of the right inferior hip pressure ulcer was performed, with measurements documented before and after debridement. The DON stated that surgical debridement removes dead skin cells for proper wound healing and that a delay in debridement could affect and slow down the resident’s wound healing.
Failure to Monitor and Document Antibiotic Use and Adverse Effects
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement its antibiotic stewardship, infection surveillance, and medication administration policies for one resident receiving antibiotics. The resident was admitted with diagnoses including an unspecified thoracic vertebra wedge compression fracture, essential hypertension, and generalized muscle weakness. A History and Physical dated 12/5/2025 documented that the resident had capacity to understand and make decisions, while the MDS dated the same day indicated severely impaired cognitive skills for daily decisions and dependence on staff for toileting, showering, and dressing. On 12/11/2025, a physician’s order directed cephalexin 500 mg by mouth twice daily for seven days for a UTI, and the resident’s care plan for history of UTI included interventions to administer medications as ordered and monitor for side effects, reporting them to the physician if noted. On 12/14/2025, the physician’s order was changed to ciprofloxacin 500 mg by mouth twice daily for seven days for UTI. The MAR for December 2025 showed that the resident received cephalexin from 12/11/2025 at 5 p.m. to 12/14/2025 at 5 p.m., and ciprofloxacin from 12/15/2025 at 9 a.m. to 12/21/2025 at 5 p.m. During interviews and concurrent record review on 1/6/2026, the Infection Preventionist stated that residents on antibiotics such as cephalexin and ciprofloxacin are to be monitored every shift for signs and symptoms of infection and any adverse reactions, with documentation in progress notes. The Infection Preventionist confirmed there was no documented antibiotic monitoring for adverse effects of cephalexin on 12/11/2025 and 12/12/2025 from 3 p.m. to 11 p.m., and no documented monitoring for adverse effects of ciprofloxacin on 12/15/2025 and 12/16/2025 from 7 a.m. to 3 p.m., and on 12/18/2025 from 3 p.m. to 11 p.m. RN 1 and the DON both stated that nurses are expected to monitor antibiotic use and adverse effects every shift and document in the medical record. Facility policies on Antibiotic Stewardship, Surveillance for Infections, and Administering Medications required monitoring and documentation of antibiotic use, signs and symptoms of infection, and any complaints, symptoms, and results related to medications, which were not followed during the identified shifts.
Failure to Safeguard Resident EHR Results in Breach of Confidentiality
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to maintain the privacy and confidentiality of a resident's electronic health record (EHR) by leaving it open and unattended at a nurses' station. The LVN admitted to logging into the computer and then walking away, leaving the EHR visible and the computer out of her sight. The LVN acknowledged that she should have logged off the computer and not left it open and unattended. The resident whose information was exposed had been admitted with diagnoses including muscle weakness, a history of falling, and dementia, and required substantial assistance with daily activities. The Director of Nursing (DON) confirmed that staff are required to turn off computers when leaving them unattended to prevent unauthorized access to protected health information, as outlined in the facility's policy and procedure for safeguarding electronic protected health information (e-PHI).
Failure to Obtain Informed Consent for Bed Alarm Use
Penalty
Summary
The facility failed to obtain informed consent from a resident's responsible party (RP) prior to the use of a bed alarm, which is considered a safety device that alerts staff when a resident attempts to get out of bed. The resident in question was admitted with diagnoses including muscle weakness, a history of falls, and dementia, and was assessed as lacking the capacity to make medical decisions. Following a fall, the medical doctor ordered the use of a bed alarm, and the device was implemented immediately. However, documentation and interviews revealed that informed consent from the resident's RP was not obtained until nearly two weeks after the bed alarm was put in place. The care plan and medical records indicated that the resident was at high risk for falls and required substantial assistance with daily activities. Despite facility policy requiring written physician orders and consent from the resident or their representative before using restraints or similar safety devices, the bed alarm was used without prior consent. The Director of Nursing confirmed that consent should have been obtained at the time the bed alarm was ordered and acknowledged the lapse in following the facility's policy and procedures.
Contradictory Diet Orders and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and consistent medical records for one resident, resulting in two active physician orders that directly contradicted each other. The resident, who was admitted with diagnoses including muscle weakness, history of falls, and dementia, had orders for both 'nothing by mouth' (NPO) and a clear liquid diet at the same time. The medical record review showed that after a gastrointestinal bleed, the resident was initially placed on TPN and NPO status, with subsequent orders for clear liquids added after a surgical follow-up. However, the NPO order was not discontinued when the clear liquid diet was started, leading to both orders being active simultaneously. Staff interviews confirmed awareness of the conflicting orders, with both the Quality Assurance Nurse and the DON acknowledging that the presence of both NPO and clear liquid diet orders could cause confusion and was not accurate documentation. Observations revealed that the resident had a tray with clear liquid items at bedside that had not been consumed, and staff expressed concern that the contradictory orders could impact the resident's care. The facility's policy requires documentation to be objective, complete, and accurate, which was not met in this instance.
Failure to Document Intermittent Catheterization Procedure
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who required intermittent catheterization. Specifically, although a physician's order was in place for a straight catheter to collect a urine sample, the procedure was performed by an LVN but not documented in the resident's medical record. Both the LVN and the Director of Nursing confirmed that the procedure and the resident's response should have been recorded, as this information is essential for communication regarding the resident's care and safety. The resident involved had diagnoses including anxiety disorder, urinary tract infection, and diabetes mellitus, and was assessed as having intact cognitive function and requiring maximal assistance for toileting hygiene and lower body dressing. Facility policy required detailed documentation of catheterization procedures, including date, time, staff involved, urine characteristics, resident response, and any complications. The lack of documentation was contrary to both facility policy and accepted professional standards.
Failure to Report and Document Resident Grievance Regarding X-ray Technician Conduct
Penalty
Summary
The facility failed to ensure that a resident's grievance was reported, investigated, and documented according to its established grievance policy. A resident, admitted with diagnoses including post-joint replacement aftercare, osteoarthritis, and type 2 diabetes, reported that a male x-ray technician entered her room late at night without knocking, did not introduce himself, and did not explain the procedure, causing her distress. The resident was cognitively intact and able to make decisions at the time of the incident. Despite the resident voicing her complaint to a CNA, the concern was not reported to licensed nursing staff, nor was it documented in the resident's records or on a grievance form. Interviews with facility staff confirmed that the complaint was not communicated to the appropriate personnel, and a review of facility policies indicated that all staff are required to report such grievances. The Director of Nursing acknowledged that the complaint was not addressed as required by policy, and that this failure could negatively affect the resident's mental health.
Delayed Provision of Medical Records Following Resident Requests
Penalty
Summary
The facility failed to provide copies of medical records within the required timeframe for two residents following written requests. For one resident, who had diagnoses including acute respiratory failure, end stage renal disease, and was dependent on renal dialysis, a request for medical records was made through a law office. The facility acknowledged receipt of the request, but there was a delay in sending the invoice and the records, which were ultimately provided 18 days after the initial request. The delay was attributed to the facility's attempt to collect additional records from an external dialysis center, but the invoice was eventually sent without those records. For another resident, who had chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and adult failure to thrive, a family member requested medical records and provided the necessary authorization. The facility delayed providing the invoice and did not supply the requested records within the 48-hour policy window. The Medical Records Director confirmed that the records were not provided in a timely manner and could not provide documentation that the records had been sent as of the date of the interview. The facility's policy required records to be provided within 48 hours, excluding weekends and holidays, but this was not followed in both cases.
Failure to Maintain Complete Medical Records for Dialysis Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident when the resident's Dialysis Communication Records binder went missing. The resident, who had diagnoses including acute respiratory failure, end stage renal disease, and was dependent on renal dialysis, was admitted and later readmitted to the facility. The resident required substantial to maximal assistance with daily activities and had a scheduled dialysis regimen. On a specified date, the resident was transferred from the dialysis center to a general acute care hospital due to altered mental status and did not return to the facility, resulting in the facility not receiving the Dialysis Communication binder back. Interviews with facility staff revealed that the binder, which is used to document and communicate care between the facility and the dialysis center, was not retrieved after the resident's transfer. The Director of Nursing confirmed that nurses are responsible for ensuring the binder accompanies the resident and is returned, but in this case, the binder was not recovered and staff did not communicate with the dialysis center to retrieve it. The facility's policy requires that documentation in the medical record be objective, complete, and accurate, but the missing binder resulted in incomplete records for the resident.
Failure to Notify Physician and Representative of Significant Change in Condition
Penalty
Summary
The facility failed to notify the attending physician and the resident's representative when a significant change in condition occurred for one resident. The resident, who had a history of prostate cancer, chronic kidney disease stage 3, and acute respiratory failure with hypoxia, was admitted and later readmitted to the facility. On a specific date, the resident was noted to have hematuria (blood in the urine), which constituted a significant change in condition as defined by the facility's policy. Review of the resident's records showed that a urinalysis and urine culture were ordered and sent to the laboratory due to the presence of blood in the urine and lower abdominal pain. Laboratory results indicated elevated white and red blood cells and a positive urine culture for proteus mirabilis, a common cause of urinary tract infections. Although the urinalysis result was reported to the physician, there was no documentation that a Change of Condition (COC) note was created at the time the hematuria was first observed, nor was there evidence that the resident's representative was notified as required by facility policy. Interviews with the Quality Assurance Nurse and the Director of Nursing confirmed that the facility's protocol required immediate creation of a COC note, notification of the physician, and notification of the resident's representative when a significant change in condition was identified. Both staff members acknowledged that these steps were not documented or verifiable for the date when the hematuria was first observed, indicating a failure to follow established procedures for timely notification.
Failure to Develop and Implement Care Plan for Change in Condition
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who experienced a change in condition, specifically hematuria (blood in the urine). The resident, who had a history of prostate cancer, chronic kidney disease stage 3, and acute respiratory failure with hypoxia, was admitted and later readmitted to the facility. On the date of the change in condition, a physician's order for urinalysis was obtained due to hematuria, and a subsequent order for urine culture was placed for lower abdominal pain. However, there was no care plan created or revised to address the new onset of hematuria at that time. The resident's existing care plan addressed frequent incontinence and related issues but did not include interventions specific to the new condition of hematuria. Progress notes indicated that the urinalysis result was reported to the physician, but no new orders were given, and no change in condition (COC) note was created for the hematuria event. The lack of a COC note meant that the care planning process was not initiated for this new issue, and interventions to monitor and address hematuria were not implemented until several days later, after a positive urine culture result. Facility staff confirmed that the absence of a timely care plan for hematuria could result in a lack of monitoring and appropriate interventions.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting an injury of unknown origin for a resident. The resident, who had severe cognitive impairment and multiple diagnoses including dysphagia, anxiety, and type 2 diabetes, was admitted to the facility and later found with a bruise and swelling on the right side of the face. The injury was first noted by a CNA and reported to an LVN, who then informed an RN. Despite the facility's policy requiring immediate reporting of such injuries to local, state, and federal agencies, the injury was only reported to a doctor and not to the Survey State Agency. Interviews with staff revealed that the injury was not associated with a reported fall, and the Director of Nursing confirmed that the unknown injury was not reported to the appropriate authorities as required. The facility's policy, revised in September 2022, mandates that all reports of resident abuse, including injuries of unknown origin, be reported immediately to the administrator and other officials according to state law. This failure to report the injury as per the policy placed the resident at risk for further injury.
Failure to Develop Baseline Care Plan for Resident with Epilepsy
Penalty
Summary
The facility failed to develop a baseline individualized care plan for a resident with a history of epilepsy within 48 hours of admission. The resident, who was admitted with diagnoses including unspecified epilepsy, Alzheimer's disease, and other coordination issues, did not have a care plan addressing safety precautions related to their seizure history. The resident's medical records indicated severe cognitive impairment and a need for maximum assistance with daily activities, yet the care plan only included basic interventions such as notifying family and physicians, administering medications, and consulting neurology as ordered. The resident experienced seizures on multiple occasions, with the first documented seizure occurring shortly after admission. Despite the resident being on multiple antiepileptic medications, the care plan lacked specific seizure precautions such as padded side rails and foam padding on sharp edges to prevent injury. Interviews with facility staff, including a Licensed Vocational Nurse and a Registered Nurse, revealed that there was no care plan for seizure precautions or fall risk, which should have been created upon admission. The Director of Nursing and the MDS Nurse acknowledged the absence of a care plan for seizure history and emphasized the importance of individualized care plans to ensure resident safety. The facility's policy and procedure documents indicated that a baseline care plan should be developed within 48 hours of admission to address immediate health and safety needs, but this was not done for the resident in question. The lack of a comprehensive care plan for seizure precautions and fall risk compromised the quality of care provided to the resident.
Failure to Maintain Cleanliness and Adequate Room Temperatures
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the condition of Resident 22's electric fan and the room temperatures for Residents 71, 95, and 17. Resident 22, who was readmitted with acute on chronic respiratory failure and required total assistance with activities of daily living, had an electric fan in their room that was visibly dusty. The Registered Nurse confirmed the presence of gray powder-like material on the fan, which was identified as dust. The Maintenance Supervisor and Director of Nursing acknowledged that housekeeping was responsible for cleaning such equipment, and the failure to do so could lead to unclean air circulation and potential allergens. Additionally, the facility did not maintain the required room temperature range of 71 to 81 degrees Fahrenheit for Residents 71, 95, and 17. Resident 95 reported difficulty sleeping due to the cold room temperature, while Resident 17 expressed frustration over the cold air blowing from the air conditioning at night. Despite complaints, the Maintenance Supervisor only checked room temperatures during the day and did not address the nighttime temperature issues. Resident 71 also reported feeling cold at night and requested extra blankets. Interviews with staff, including the Licensed Vocational Nurse and Director of Nursing, confirmed that the maintenance department was informed of the temperature issues, but the problem persisted. The facility's policy on maintaining a homelike environment, which includes comfortable and safe temperatures, was not adhered to, potentially affecting the residents' quality of life.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to potential delays in necessary care and services. One resident, who was admitted with hemiplegia, hemiparesis, and diabetes mellitus, required continuous supplemental oxygen. However, there was no care plan addressing the use of oxygen, despite the resident's behavior of frequently removing the nasal cannula. This oversight was confirmed by multiple staff members, including a Registered Nurse and the Director of Nursing, who acknowledged the importance of having a care plan to ensure proper oxygen administration and resident safety. Another deficiency involved the same resident who was receiving treatment for diabetes mellitus. The facility did not have a care plan for managing the resident's diabetes, which is crucial for monitoring blood sugar levels and administering medications like insulin and metformin. The absence of a care plan for diabetes was noted by the Minimum Data Set Coordinator and the Director of Nursing, who emphasized the risk of missing critical interventions without a documented plan. Additionally, the facility failed to develop a care plan for a resident using upper grab bars/side rails, which are considered physical restraints. There was no physician's order, assessment, or informed consent for the use of these devices, and no care plan was in place to ensure their necessity and safety. Furthermore, another resident diagnosed with depression and prescribed amitriptyline did not have a care plan with measurable goals for monitoring the effectiveness of the medication. The Director of Nursing confirmed the lack of a care plan for depression and medication use, highlighting the facility's failure to provide patient-centered care and monitor treatment outcomes effectively.
Failure to Provide Adequate ROM and Mobility Services
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in range of motion (ROM) and mobility for three residents. For one resident, the Restorative Nursing Aides (RNAs) did not perform passive range of motion (PROM) exercises on the knees as ordered by the physician, citing that the knees could not bend. This was not reported to the therapy staff, which was a requirement if any part of the order could not be completed. The resident's care plan indicated a risk for further decline in ROM, and the order summary report specified PROM exercises for all extremities, which were not fully executed. Another resident did not receive appropriate monitoring of ROM by therapy staff on a quarterly basis. The facility's system for monitoring ROM was ineffective, as it relied on visual assessments and staff interviews rather than objective measurements. The Director of Rehabilitation (DOR) acknowledged that the current system would not show if a resident developed a contracture, as it lacked objective measures with degrees of movement at each joint. The facility's policy indicated that residents with limited ROM should receive treatment to prevent further decrease, but this was not effectively implemented. A third resident had an RNA order discrepancy, where PROM exercises were ordered five times a week, but splint application was ordered six times a week. The DOR stated that PROM should be performed before splint application to ensure proper joint movement and prevent injury. The facility's policy indicated that residents with limited mobility should receive appropriate services to maintain or improve mobility, but this was not adhered to in practice.
Facility Fails to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents. For two residents, fall mats designed to prevent injury were improperly used, with side tables placed on top of them, creating instability and potential for injury. This was confirmed by CNAs and the Director of Nursing (DON), who acknowledged that such placement could lead to the tables falling on residents. The facility's policy on managing falls and fall risks was not adhered to, as it emphasizes the need for safe room arrangements to prevent falls. Another resident's bed pad alarm, intended to alert staff when the resident leaves the bed, was found non-functional. Despite the resident being at risk for falls, the alarm did not sound when the resident was out of bed. CNAs acknowledged the malfunction and the responsibility to ensure alarms are operational. The DON confirmed that staff should test alarms daily to prevent unsupervised bed exits, as outlined in the facility's policy. Additional hazards included frayed wires on a resident's bed remote control, which posed a risk of electrical shock. The maintenance department was responsible for addressing such issues, but the incident was not reported promptly. Furthermore, a resident's bed was left in an elevated position, increasing the risk of severe injury from falls. The DON confirmed that beds should be kept low to minimize injury risk. Lastly, an oxygen concentrator was improperly placed on a floor mat, risking instability and potential accidents. The facility's policies on hazardous areas and equipment were not followed, as heavy items should not be placed on floor mats to ensure resident safety.
Deficiencies in Enteral Feeding Management
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for two of three sampled residents. For Resident 94, the Licensed Vocational Nurse (LVN 4) did not check for residuals before administering the gastrostomy tube feeding, despite physician orders requiring this step. The resident, who had a history of hemiplegia and dysphagia, was dependent on enteral feeding. During an observation, LVN 4 admitted to not checking for residuals due to nervousness, acknowledging the importance of this step to prevent potential complications such as aspiration pneumonia. For Resident 60, the facility did not label the water flush bag with the rate of delivery, which is crucial for ensuring the correct amount of water is administered. The resident, who had dysphagia and diabetes, was dependent on tube feeding and unable to make decisions. During an interview, the Director of Nursing (DON) confirmed the omission and emphasized the importance of labeling to prevent over or under hydration. Resident 68's enteral feeding and water flush bags were not labeled with the administration rate, contrary to facility policy. The resident, with a history of acute respiratory failure and severely impaired cognition, required total assistance with daily activities. Observations revealed that the bags were missing critical information, which was confirmed by both LVN 1 and RN 1. The DON reiterated the necessity of accurate labeling to ensure the resident receives the prescribed amount of nutrition and hydration.
Improper Medication Disposal and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to properly dispose of medications in one of the inspected medication rooms, as observed during a survey. Medications were found in a pharmaceutical waste bin in their original manufacturer packaging, as well as loose tablets and capsules, without any liquid poured over them to render them irretrievable. This was contrary to the facility's policy, which requires medications to be disposed of in a manner that prevents retrieval, such as by pouring liquid over them. The Registered Nurse (RN) acknowledged that the medications were not disposed of properly, which could lead to potential misuse and diversion. Additionally, the facility did not include verifying signatures of two licensed nurses on the Medication Disposition Record/Pass Log for six logged records. Both the RN and the Director of Nursing (DON) confirmed the absence of witness signatures, which is a requirement according to the facility's policy. The DON acknowledged that the failure to include witness signatures and properly dispose of medications could lead to medication diversion and accidental exposure, affecting the safety of residents and staff.
Deficiencies in Psychotropic Medication Management and Monitoring
Penalty
Summary
The facility failed to monitor the side effects of Trazodone for Resident 17, who was prescribed the medication for depression and insomnia. Despite the care plan indicating the need to monitor for side effects such as nausea, vomiting, anxiety, and dizziness, there was no documentation in the clinical chart from November 1, 2024, to December 4, 2024, indicating whether Resident 17 experienced any adverse consequences from the use of Trazodone. The Director of Nursing confirmed the absence of documentation and acknowledged the importance of monitoring to ensure the resident was free from unnecessary medications and adverse consequences. Additionally, the facility did not ensure that PRN orders for psychotropic medications were limited to 14 days for Resident 353. The resident was prescribed lorazepam for anxiety, but the order did not specify a duration, and there was no documented rationale for indefinite use. The facility's policy requires PRN orders for psychotropic drugs to be limited to 14 days unless the attending physician documents a rationale for extending the order. The Registered Nurse and Director of Nursing both acknowledged the lack of documentation and the potential risk of unnecessary medication use. The facility's policies and procedures emphasize the importance of monitoring for adverse consequences and ensuring that PRN psychotropic medications have a specified duration. However, in the cases of Residents 17 and 353, these protocols were not followed, leading to deficiencies in medication management and monitoring. The lack of documentation and adherence to policy put the residents at risk for unnecessary medication use and potential adverse effects.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 17.86% due to five errors observed out of 28 opportunities. The errors involved incorrect administration of medications to three residents. One resident received a different dose of Omega-3 Fatty Acid than prescribed, while another resident did not receive their prescribed metformin and pioglitazone for diabetes management and was given a different form of multivitamin. A third resident received a multivitamin with minerals instead of the prescribed form. The errors were observed during medication administration rounds. Licensed Vocational Nurse 5 (LVN 5) failed to administer metformin and pioglitazone to a resident and gave an incorrect multivitamin. LVN 6 administered the wrong dose of Omega-3 Fatty Acid to another resident and the wrong multivitamin to a third resident. These actions were contrary to the facility's policy and procedures, which require medications to be administered as prescribed and within one hour of the scheduled time, with the medication label checked three times to ensure the right resident, medication, dosage, time, and method of administration. Interviews with the involved nurses and the Director of Nursing (DON) confirmed the medication errors. The DON acknowledged that the nurses failed to follow the facility's medication administration guidelines and the 5 rights of medication administration. The facility's policy defines a medication error as any preparation or administration of drugs not in accordance with physician's orders, manufacturer specifications, or accepted professional standards, which includes omissions, wrong doses, and wrong drugs.
Failure to Prepare Puree Foods to Required Consistency
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs for residents on a puree diet, specifically level four, which requires food to be soft and pudding-like in consistency. During an observation of the lunch trayline, it was noted that the puree Boston baked beans did not hold their shape when served, and the puree cabbage was weeping liquid on the resident's plate. This inconsistency in food texture was confirmed during a test tray evaluation with the Dietary Supervisor and Diet Aide, who acknowledged that the puree foods should hold their shape and not be watery. The facility's policies and procedures, as well as the diet manual, specify that therapeutic diets, including textured-modified diets, should be prepared and served using safe, sanitary food practices, and the puree diet should be lump-free, not firm or sticky, and hold its shape on a plate. The facility's recipe for puree Boston baked beans and steamed cabbage included the use of a thickener to ensure the correct consistency, but the finished products did not meet the required standards. The International Dysphagia Diet Standardization Initiative (IDDSI) guidelines for Level 4 Pureed foods state that the food should fall off a spoon in a single spoonful when tilted and continue to hold its shape on the plate, with no separation of liquid from solid. The failure to adhere to these guidelines and recipes resulted in the potential for adverse outcomes for 11 of the 76 residents on a puree/level 4 diet, as the improper food texture could lead to issues such as aspiration, weight loss, and malnutrition.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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