New Vista Post-acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 1516 Sawtelle Blvd., Los Angeles, California 90025
- CMS Provider Number
- 055473
- Inspections on file
- 80
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 45
Citation history
Health deficiencies cited at New Vista Post-acute Care Center during CMS and state inspections, most recent first.
A resident with cancer, muscle weakness, and Type 2 DM had an order for a daily Asperflex lidocaine 4% patch for pain management but repeatedly refused the medication. Despite these refusals, the MAR documented that the patch was applied and removed as scheduled, and nursing staff, including LVNs and the DON, acknowledged that the refusals were not reported to the physician or clinical supervisors as required. Facility policy stated that when a resident refuses care, treatment, medications, or food, the attending physician must be notified within 72 hours, but this notification did not occur.
A resident with cancer, muscle weakness, and Type 2 DM had a daily Asperflex lidocaine 4% patch ordered for pain management, with specific application and removal times. Despite the resident repeatedly refusing the patch because it was believed to be unnecessary or ineffective, an LVN documented on the MAR that the patch was applied on multiple occasions. The ADON and DON confirmed that this documentation implied the medication was given and was inaccurate, and the DON reported not being informed of the refusals, contrary to facility policies requiring accurate medication administration and timely physician notification when care or medications are refused.
Two residents who were cognitively intact but dependent on staff for ADLs reported missing multiple scheduled showers over a one- to two-month period. One resident with spinal stenosis, acute kidney failure, and muscle weakness, and another with lack of coordination, generalized muscle weakness, and hypertension, both stated they were supposed to receive showers twice weekly but did not, and one reported being told by CNAs that staff were unavailable or too busy. A CNA reported being assigned about 12 residents and lacking time to complete all care, while an LVN, RN supervisor, and DON acknowledged that residents have pre-planned shower schedules, are largely dependent on staff for ADLs, and that CNA staffing shortages and sick calls affect the provision of scheduled showers and hygiene.
A resident with spinal stenosis, acute kidney failure, muscle weakness, and significant ADL dependence did not receive ongoing PT/OT services because the facility failed to facilitate use of the resident’s secondary insurance after the primary insurance’s limited coverage ended. PT was discontinued after a short period and the resident was discharged to an RNA program, despite a hospital physician’s recommendation for extended PT/OT and the resident’s expressed desire and potential to benefit from more therapy. The DOR, RN supervisor, and RNA staff acknowledged the resident could have benefited from additional PT/OT, while SS and the DON were unaware that therapy had been interrupted due to insurance and that SS might be responsible for securing additional resources, contrary to facility policy requiring provision or arrangement of needed specialized rehabilitative services.
The facility failed to follow its abuse prevention and conduct policies by assigning a CNA to two residents who had requested not to receive care from that CNA and by not honoring a resident’s objection at the time of care. One cognitively intact resident with hemiplegia and multiple comorbidities reported prior negative interactions with the CNA and again objected to her assignment, yet the CNA was still assigned and an altercation occurred during incontinent care, with conflicting accounts about whether the CNA threw a towel at the resident’s face or the resident threw a towel and kicked the CNA. Another resident with severely impaired cognition and significant physical limitations reported that the same CNA roughly grabbed and turned him and was rude, and he requested that the CNA no longer care for him. Staff interviews showed inconsistent awareness and communication about which residents the CNA was restricted from caring for, resulting in assignments that did not respect resident preferences and led to loud arguments and possible physical abuse.
The facility did not maintain adequate nursing and CNA staffing levels as required by its own staffing policy, with documented DHPPD for total nursing and CNAs falling below the facility’s stated minimums on most reviewed days and only five CNAs assigned to 79 residents on one shift. A resident with hemiplegia, epilepsy, and muscle weakness who needs moderate to extensive assistance with ADLs reported that scheduled showers were delayed because there were not enough staff, and a CNA confirmed being unable to provide the shower due to short staffing. The CNA also stated that when residents have private caregivers, the facility allows those caregivers to perform CNA tasks such as feeding, repositioning, changing, and cleaning to reduce staff workload.
A resident with ESRD, toxic encephalopathy, and type II DM had ongoing generalized rash, intense itching, and diffuse excoriations, and was repeatedly treated with permethrin and ivermectin for suspected scabies. Despite clear signs and symptoms and documentation in progress notes and an SBAR, the facility did not perform diagnostic skin scrapings as required by its scabies P&P. The IPN acknowledged the resident had scabies-like symptoms and that scabies is contagious, yet no contact tracing list was developed and no education or in-services on scabies were provided to staff, family members, or visitors, contrary to the facility’s written scabies prevention and control policy.
The facility failed to maintain several resident rooms free of water leaks, resulting in water dripping from ceilings and entering through a window, with towels, blankets, and basins placed on floors to collect the water. One resident with spinal stenosis, polyneuropathy, and type II DM who needed extensive ADL assistance reported feeling water dripping from the ceiling and had their bed moved to avoid getting wet. Another resident with hemiplegia, epilepsy, and muscle weakness was observed with active ceiling leaks and visible ceiling discoloration. The MTD acknowledged ongoing roof and window leak issues despite prior repairs, and the DON stated that such leaks and water on the floor put residents at risk of injury and that residents should have been moved to ensure a safe environment.
A resident with dementia and multiple Stage 4 pressure ulcers, fully dependent for ADLs, had a care plan and physician orders requiring q2h turning, offloading with wedges, frequent incontinence care, and use of an appropriate pressure‑reducing mattress. Facility ADL logs showed the resident was turned only two to three times per day, and interviews with a private caregiver and a CNA confirmed that the private caregiver performed most ADLs while staff documented limited repositioning, contrary to facility policies requiring q2h turning. On readmission, required skin and pressure ulcer risk assessments were not documented, and both the DON and treatment nurse acknowledged that the absence of documentation meant the assessments were not completed. Observation further revealed that the resident’s low air loss mattress was set to a firm 250‑lb setting despite the resident weighing about 156–158 lbs, and staff confirmed that the LAL mattress should be set according to weight, meaning the mattress was not properly configured for pressure ulcer prevention and management.
A resident with hemiplegia, gait abnormalities, a history of falls, and mildly impaired cognition experienced falls associated with wheelchair transfer and being found on the floor. The resident’s fall risk care plan identified multiple fall-related problems and required assistance with transfers, but fall risk evaluations were inaccurately completed, including incorrect scoring for recent fall history and leaving gait/balance items blank despite documented balance and gait issues. Required 72-hour post-fall neuro checks were not consistently performed or documented on all shifts after the fall, and nursing leadership acknowledged incomplete and inconsistent charting that did not follow facility fall and post-fall assessment policies.
A resident with severe dementia, depression, and psychoactive substance abuse was admitted after hospitalization for failure to thrive and psychostimulant use disorder and was documented as lacking decision-making capacity. On admission, the resident scored as high risk for elopement, and staff documented multiple episodes of wandering and exit-seeking behavior, including repeated attempts to leave the building and verbal insistence on going home. Despite facility policy requiring use of the SBAR process and physician notification for significant changes and high elopement risk, the physician was not notified and no wander guard order was obtained. Overnight, after several documented redirections, the resident was later found to be missing from the room and the facility, and was subsequently located by police in another city with bruises and scratches.
A resident with dementia, depression, psychoactive substance abuse, and documented severe cognitive impairment was admitted and assessed as high risk for elopement, but staff did not notify the physician or develop and implement an elopement-focused care plan as required by facility policy. Preadmission records and an elopement risk assessment identified the risk, and visual check logs and nursing notes documented multiple episodes of wandering and exit-seeking behavior throughout the evening and night, with the resident expressing a strong desire to leave and being difficult to redirect. Despite these behaviors, no individualized elopement interventions were care planned, and no wander guard order was obtained. By early morning, staff discovered the resident was no longer in the room or facility, and the resident’s whereabouts were unknown for many hours until police later located the resident in another city with bruises and scratches.
Two residents did not receive physician-ordered wound and catheter treatments as required, and treatment documentation was incomplete or inaccurate. One resident, with a suprapubic catheter and pressure-related wounds, had an IDT assessment indicating it was not safe for self-administration of drugs, yet a nurse charted daily catheter flushes as completed while relying on the resident’s report that he did them himself, without observing or assessing this and without documenting refusals or missed treatments on the TAR. The same resident reported not receiving daily skin treatments on at least one day due to lack of a treatment nurse, and the TAR showed blank entries for ordered catheter care and wound care without explanation. A second resident with sacrococcyx and skin conditions had physician orders for daily sacral wound care and topical ketoconazole, but the TAR contained multiple blank entries for these treatments with no documentation of completion, refusal, or reason for omission, contrary to facility policies requiring IDT determination for self-administration and detailed skin care documentation.
Staff did not obtain informed consent from the appropriate representative for a resident with cognitive impairment and lacking decision-making capacity, instead documenting the resident's own verbal declination for COVID-19 and influenza vaccines, contrary to facility policy and procedures.
The facility did not ensure that several residents received required COVID-19, pneumonia, and influenza vaccines despite consent, and failed to document vaccine administration. Staff members, including CNAs and an LVN, were observed not following hand hygiene and PPE protocols, and had not been properly fit tested for N95 masks. High-touch surface disinfection was not consistently documented, and contaminated linen was improperly handled, all in violation of facility policies.
A CNA dropped a clean towel on the floor, mixed it with other clean linens, and intended to use it on a resident with complex medical needs, including a tracheostomy and acute respiratory failure. The incident was observed by a surveyor, and staff interviews confirmed this action violated infection control protocols, as facility policy requires any linen that touches the floor to be treated as contaminated.
A resident with diabetes and cognitive impairment experienced untreated bilateral itchy and discolored eyes for an extended period. Despite observations by staff and reports from a family member, symptoms were not communicated to medical staff, and no ophthalmology referral or evaluation occurred. Record review confirmed the absence of eye doctor visits or orders, and facility leadership acknowledged the lack of adherence to eye care policy and documentation.
A resident with severe cognitive impairment and total dependence on staff was moved to different rooms on two occasions without notifying the family member, as required by facility policy. The family member was not consulted about the changes, which resulted in the resident being placed in a crowded room with limited space for care and personal belongings. Interviews and record reviews confirmed the lack of required notification and documentation.
A resident with severe cognitive impairment and bilateral hearing loss was not protected from misappropriation of personal property when their cochlear hearing aid went missing. Despite the family reporting the loss and the item being listed in the resident's inventory, staff did not document a required theft and loss report or complete the investigation steps outlined in facility policy, resulting in the resident's continued inability to hear.
A resident with severe cognitive impairment and dependence on staff for ADLs exhibited repeated behaviors of removing hand mittens and pulling on their tracheostomy and g-tube, resulting in a dislodged g-tube. Despite staff interventions and documentation of these behaviors, the care plan did not address these specific risks, contrary to facility policy requiring comprehensive, individualized care planning.
A resident with diabetes and ventilator dependence did not receive blood sugar monitoring according to physician orders, as a nurse performed the check at an unscheduled time and did not administer insulin as ordered. Additionally, after the resident's death, required documentation—including the death certificate and physician's note on cause of death—was not completed per facility policy.
A resident with multiple fractures and recent surgery experienced prolonged, uncontrolled pain due to delays in administering prescribed hydromorphone, lack of timely access to the emergency medication kit, and incomplete pain assessment documentation. Staff interviews and record reviews confirmed that pain management protocols were not consistently followed, resulting in the resident requiring hospital transfer for severe pain.
A CNA was observed changing a dependent resident's incontinence brief in a shared room with the privacy curtain open, leaving the resident exposed and failing to maintain dignity and privacy. The CNA could not explain the importance of privacy and responded confrontationally when questioned, while an LVN confirmed the incident. Facility policy requires residents to be treated with dignity and respect at all times.
A LVN crushed and administered multiple medications together without a physician's order and failed to verify a resident's identity or review orders prior to administration. Additionally, a CNA provided incontinence care to another resident without ensuring privacy, leaving the resident exposed in a shared room. Both incidents demonstrate a lack of staff competency in medication management and resident rights.
A nurse failed to properly identify a resident before preparing and administering morning medications, crushed multiple medications together without a physician's order, and was unable to verify which medications were being given. The medications were mixed in applesauce and administered without following required procedures for resident identification or medication verification, contrary to facility policy.
Licensed nursing staff did not consistently document their initials and signatures on the MARs for three residents receiving medications for conditions such as hypertension, ESRD, diabetes, and glaucoma. This resulted in incomplete medical records, as required by professional standards, with multiple staff acknowledging the deficiency during interviews and record reviews.
A facility failed to maintain a clean and homelike environment in a resident's room due to a ceiling leak that had persisted for months. The room, occupied by a resident with complex medical conditions, was cluttered with blankets and basins used to absorb water, creating potential hazards for falls and accidents. Staff and administration acknowledged the issue, and subsequent inspections confirmed the leak had been repaired.
The facility failed to ensure the CM had the necessary skills for a seamless admission process, as outlined in their policy. The CM, working remotely, was unreachable due to a full voicemail, delaying resident admissions. This impacted the residents' care plans and service delivery.
A facility failed to report an alleged abuse incident involving a cognitively impaired resident to the California Department of Public Health. The incident involved inappropriate touching by another resident, which was observed by an LVN and considered sexual abuse. The Facility Administrator acknowledged the failure to report to the Department of Public Health, although the police were contacted. This failure delayed the State Agency's investigation, potentially exposing the resident to further abuse.
Two residents reported missing and damaged clothing after using the facility's laundry services. Despite clothes being labeled, one resident did not receive his clothes back, and another found her T-shirt bleached and worn by another resident. Staff interviews revealed a lack of awareness and inadequate response to the grievances, highlighting a failure in the facility's grievance policy implementation.
The facility failed to maintain the dignity of two residents during meal assistance. A CNA stood over a resident with dementia while feeding her, contrary to policy requiring staff to be seated at eye level. Another resident, who is visually impaired, was not informed about the food items and their placement on the tray, as required by facility policy.
A CNA failed to maintain a resident's privacy by not closing the privacy curtain during personal care, exposing the resident to roommates and an outside view. The resident, with severely impaired cognition and total dependence on staff, was left without privacy despite facility policies emphasizing the importance of maintaining privacy during personal care activities.
A facility failed to maintain a safe and homelike environment for a resident with Raynaud's syndrome, schizophrenia, and depression. The resident's room had a broken window frame and detached glass, allowing cold air to enter, causing discomfort. Observations confirmed the disrepair, and the facility's policy on maintaining a clean and comfortable environment was not followed.
A resident with multiple medical conditions and severely impaired cognition was using hand mitten restraints without a comprehensive care plan in place. Despite physician orders and facility policy requiring such a plan, staff interviews confirmed the absence of a care plan to guide interventions and goals, highlighting a deficiency in the facility's adherence to its procedures.
A resident with hemiplegia, diabetes, and hypertension did not receive prescribed restorative nursing assistance for passive range of motion (PROM) therapy as per physician's orders. The therapy was missed on nine days in November, including a week where it was only provided once instead of three times. Interviews with staff confirmed the deficiency, and the facility's policy on ROM exercises was not followed.
A resident at high risk for falls experienced an unwitnessed fall despite having a care plan with interventions like a tab alarm and supervision. The fall led to a subdural hematoma, requiring hospital transfer and ICU admission. The facility failed to report the incident per guidelines.
A resident's tube feeding equipment was not labeled according to facility policy, posing a potential infection risk. The resident, with conditions including dysphagia and ventilator dependence, had unlabeled feeding equipment, confirmed by staff observations and interviews. The facility's policy required specific labeling for infection control, which was not followed.
The facility failed to prevent staff food from being stored in the kitchen refrigerator, violating infection control protocols. Observations revealed personal food items, such as a coffee cup and soda, in the refrigerator, which were not intended for residents. Interviews with the Dietary Supervisor and DON confirmed that staff food should be stored separately to prevent foodborne illness risks.
A facility failed to ensure proper infection control by not providing hand hygiene for a resident before meals and not labeling tube feeding equipment for another resident. The first resident, with conditions like encephalopathy, ate with bare hands without washing them, while the second resident's tube feeding equipment lacked necessary labels, risking infection and incorrect formula administration.
A resident with cognitive impairment received an influenza vaccine without prior informed consent from their responsible party. The vaccine was administered before consent was obtained, violating the facility's policy and the responsible party's right to make informed medical decisions.
A resident with severe cognitive impairments was not protected from physical abuse by another resident, despite the facility being aware of ongoing inappropriate behavior. The facility failed to address the situation, leading to an altercation where one resident hit the other. Staff had reported the behavior to administration, but no effective measures were taken.
A facility failed to investigate and address ongoing harassment and abuse between two residents, leading to a physical altercation. Despite Resident 1's impaired cognition and vulnerability, Resident 2's persistent marriage proposals and verbal harassment were not adequately managed. Staff awareness of the situation did not translate into effective action, violating facility policies on behavior assessment and abuse prevention.
A resident with severe cognitive impairment and dependency on staff for daily activities did not receive a required PT/OT evaluation despite a physician's order. The Director of Rehabilitation confirmed the absence of rehabilitation services, and the Medical Records Director noted no records of such services. The facility's policy mandates treatment to prevent functional decline, which was not followed.
A resident with a history of leaving against medical advice eloped from the facility due to inadequate supervision. Despite being cognitively intact, the resident was at risk for elopement, as noted in their care plan. On the day of the incident, the resident left the facility through the front door without staff present in the lobby area. Staff interviews revealed inconsistent monitoring and documentation of the resident's whereabouts, and the facility's policies for routine checks were not adequately followed.
A facility failed to monitor and secure residents' personal foods in a shared refrigerator, leading to potential issues of missing food and compromised infection control. A resident reported missing food brought by family, and an observation revealed the refrigerator was unlocked and contained unlabeled food items. The Dietary Supervisor and DON confirmed that the refrigerator should be locked and food labeled according to policy.
The facility failed to hold Resident Council Meetings for several months, contrary to their policy requiring monthly meetings. Two residents, including the Resident Council President, expressed concerns about the absence of these meetings, which are crucial for addressing residents' issues. The lack of an Activity Director contributed to this deficiency, as the Activity Assistant was not responsible for organizing the meetings, and the DON confirmed the absence of meeting minutes for two months.
A facility failed to update a resident's POLST, resulting in conflicting code status information. The resident's POLST indicated full code, while the physician's order and care plan indicated DNR. This discrepancy was confirmed by the DON during a record review, highlighting a failure to adhere to the facility's policy on advanced directives and hospice care planning.
A resident's care plan at the facility contained conflicting information regarding their code status, with the POLST indicating full code and the Physician's Orders indicating DNR. This discrepancy was identified during a review of the resident's records, and the Director of Nursing confirmed the need to clarify the order with Hospice and the physician. The facility's policies require that residents' medical decisions be honored and properly documented, which was not adhered to in this case.
Two residents in an LTC facility experienced significant medication errors. One resident did not receive medications on time due to a scheduling conflict with physical therapy, and the late administration was not documented or reported. Another resident missed three days of morning medications due to staff shortages, with inaccurate documentation in the MAR. The facility's policies on medication administration and documentation were not followed.
Two residents experienced deficiencies in medication administration and documentation. One resident received medications late due to scheduling conflicts, leading to elevated blood pressure that was not promptly addressed. Another resident did not receive medications for three days due to staffing issues, with discrepancies found in the MAR. Facility staff confirmed these lapses, indicating non-compliance with medication administration policies.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy requiring timely physician notification when a resident refuses ordered treatment. A resident with malignant neoplasm of the breast, secondary malignant neoplasm of the lung, muscle weakness, and Type 2 diabetes was admitted with an order for a daily Asperflex lidocaine 4% patch for pain management, to be applied to the back at 9 AM and removed at 9 PM. The resident’s MDS showed moderately impaired cognitive skills for daily decision-making, while the H&P documented that the resident had capacity for medical decision-making. The resident reported repeatedly refusing the lidocaine patch when it was offered, yet the MAR for early April showed documentation that the patch had been applied and removed as scheduled, which did not reflect the resident’s expressed refusals and actual care. During interviews, multiple LVNs and the DON confirmed that the resident had declined the lidocaine patch several times and that refusals should be investigated and reported to the attending physician and clinical supervisors. LVN1 acknowledged being unaware whether the refusals had been reported to the physician. LVN3 stated the resident refused the patch because it was not needed and indicated that the physician should be notified so the physician could assess the resident and consider alternative medication or discontinuation of the order. LVN7 stated that medication refusals occurring more than two or three times must be reported to the physician and clinical supervisors but acknowledged not reporting this resident’s refusals and was unaware if anyone else had done so. The DON stated that licensed staff did not bring the resident’s repeated refusals of the lidocaine patch to the DON’s or the physician’s attention. Review of the facility’s “Resident Rights–Refusal of Care” policy showed that when a resident refuses care, treatment, medications, or food, the attending physician must be notified within 72 hours, which did not occur in this case.
Inaccurate MAR Documentation of Repeatedly Refused Lidocaine Patch
Penalty
Summary
Facility staff failed to accurately document the administration and refusal of an ordered Asperflex lidocaine 4% patch for pain management for one resident. The resident, admitted with diagnoses including malignant neoplasm of the breast, secondary malignant neoplasm of the lung, muscle weakness, and Type 2 diabetes mellitus, had an MDS indicating moderately impaired cognitive skills but an H&P stating capacity for medical decision-making. The physician’s order directed application of a lidocaine 4% patch to the back once daily at 9 a.m. and removal at 9 p.m. Review of the resident’s MAR for early April showed entries by an LVN documenting that the patch was applied on multiple dates and times. However, the resident reported repeatedly refusing the lidocaine patch when offered, and stated that the MAR still showed it as applied and removed as scheduled despite these refusals. During interviews, LVN staff acknowledged that the resident had been declining the lidocaine patch because the resident did not believe it was needed or effective, and one LVN stated that the last couple of MAR entries must be documentation errors because the resident had refused the medication. The ADON and DON both confirmed that the MAR documentation implied the medication was given, and the DON stated that inaccurate documentation is misleading, inappropriate, and constitutes a medication error. The DON also reported not being informed by licensed staff that the resident had been refusing the ordered lidocaine patch, despite facility policies requiring medications to be administered per physician orders and requiring notification of the attending physician when a resident refuses care or treatment, including medications, within a specified time frame. Other LVNs interviewed stated that staff were aware the resident had declined the medication more than two or three times and that documentation errors could lead to medication errors and provide wrong information during medication regimen review.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide scheduled showers in accordance with its Activities of Daily Living, Quality of Care, Routine Resident Monitoring, and Scope of Services policy, which requires monitoring and provision of bathing/showering and personal hygiene. Two residents who were cognitively intact but dependent on staff for ADLs reported missing scheduled showers. One resident, admitted with spinal stenosis, acute kidney failure, and muscle weakness, used a wheelchair for mobility and was dependent on staff for all ADLs; this resident stated he was supposed to receive showers twice a week but had missed some. Another resident, admitted with lack of coordination, generalized muscle weakness, and hypertension, required staff assistance for transfers to the shower/tub and for bathing tasks, and reported missing a couple of showers in the last month. The second resident further stated that in the last month or two he had missed two or more showers and was told by CNAs that staff were not available, that there was construction, and that they did not have enough staff. This resident reported feeling frustrated by missing showers and services and did not want to complain to leadership because staff were busy. A CNA reported being assigned an average of 12 residents on the morning shift and not having enough time to complete all tasks, spending 10 to 45 minutes per resident depending on care needs. An LVN stated that most residents receive showers twice a week and that it is important residents receive showers on their scheduled days as it is their right. The RN supervisor and DON both acknowledged that residents have pre-planned shower schedules, that most residents are dependent on staff for ADLs, and that frequent CNA staffing shortages and sick calls affect residents’ ADL care, contributing to missed scheduled showers for the sampled residents.
Failure to Facilitate Insurance Coverage Resulting in Interrupted PT/OT Services
Penalty
Summary
The facility failed to ensure that a resident received necessary PT/OT services by not facilitating the use of the resident’s secondary insurance coverage, contrary to its Specialized Rehabilitative Services policy. The resident was admitted with diagnoses including spinal stenosis, acute kidney failure, and muscle weakness, and the MDS showed intact cognition, bilateral upper and lower extremity impairment, wheelchair dependence, and dependence on staff for ADLs. A PT evaluation and plan of treatment documented lower extremity strength deficits and the resident’s goal to walk again. PT services were provided for a limited period and then the resident was discharged to an RNA program in December, with the MDS later indicating no special treatments, procedures, or programs in the prior seven days. The resident reported that a hospital physician had recommended at least 90 days of PT/OT, but therapy was discontinued after about a month because the primary insurance only covered 32 days, despite the resident having provided secondary insurance information to the facility. The DOR confirmed that the resident could have benefited from more PT/OT and that therapy did not continue due to limitations of the primary insurance and a technical issue between the business office and the secondary insurer. The resident, RNA staff, RN supervisor, and SS director all indicated that the resident wanted more therapy and could have benefited from additional PT/OT, while SS and the DON were unaware that therapy had been interrupted due to insurance coverage issues or that SS was responsible for obtaining additional resources. The facility’s policy required it to provide or obtain specialized rehabilitative services when required by the comprehensive care plan, but this was not carried out for this resident.
Failure to Honor Resident Care Preferences and Prevent Alleged Staff Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention and rules of conduct policies by assigning a CNA to provide care to residents who had requested not to receive care from that CNA, and by not honoring a resident’s expressed objection at the time of care. Resident 4, who has intact cognition and decision-making capacity and requires assistance with multiple ADLs due to hemiplegia, lack of coordination, and other medical conditions, had previously reported negative interactions with CNA4, including an incident where CNA4 forced a glove into the resident’s hand, applied A&D ointment to the glove, and told the resident to apply it herself. Resident 4 also reported that on a later night shift, CNA4 gave her a towel to clean herself, and when the towel fell to the floor and was picked up, CNA4 told her that next time it would be worse for her and stated, “I am from [NAME]; we do not play that in [NAME],” making the resident feel less than the staff. On the night in question, Resident 4 told LVN2 at the beginning of the 11 p.m.–7 a.m. shift that she did not want CNA4 assigned to her. Despite this, LVN2 completed the staff assignment including CNA4, stating her understanding was that the only resident CNA4 could not be assigned to was Resident 5, who had previously requested not to have CNA4. RN1 confirmed that one staff member had called in sick and that CNA4 was assigned to Resident 4; RN1 acknowledged that Resident 4 did not want CNA4, but he asked Resident 4 to give CNA4 a chance, and both agreed to work together. CNA4 stated that LVN2 knew she could not work with Resident 4 but told her the assignment could not be changed, and that RN2, who usually made assignments and did not assign CNA4 to Resident 4, was on vacation. During incontinent care for Resident 4 on that shift, an altercation occurred between Resident 4 and CNA4. CNA4 reported that Resident 4 requested another CNA, but LVN3 told the resident that due to short staffing she must allow CNA4 to change her. CNA4 stated that Resident 4 dried herself and then threw the dirty washcloth at CNA4, hitting her in the abdomen, and that Resident 4 kicked her in the stomach without provocation. Resident 4, however, told LVN3 and the Social Services Director that after she dried herself and gave the towel to CNA4, CNA4 became upset, accused her of throwing the towel, and then grabbed the same towel and threw it at Resident 4’s face, causing Resident 4 to feel abused and to kick CNA4 in self-defense. LVN3 corroborated that when she entered the room, Resident 4 and CNA4 were arguing, Resident 4 alleged that CNA4 hit her in the face with a towel, and CNA4 denied throwing the towel but stated that Resident 4 had hit her. The Administrator and SSD both acknowledged that Resident 4 reported CNA4 throwing the towel at her face and that there was a prior history between them. The deficiency also involves the facility’s handling of Resident 5’s complaints about CNA4. Resident 5, who has severely impaired cognition and multiple medical conditions including non-Hodgkin lymphoma, osteoarthritis, and polyneuropathy, requires extensive assistance with ADLs and mobility. Resident 5 told CNA5 that he wanted to speak to a supervisor to report abuse, and CNA5 reported this to the charge nurse, supervisor, and Administrator. Resident 5 later stated that CNA4 grabbed his left arm, swung him to the left side, and was rude, and that he did not like how CNA4 turned him and that CNA4 did not communicate what she was going to do. The Administrator confirmed that Resident 5 stated he did not like the care he received from CNA4 and requested that CNA4 no longer be assigned to him, and that CNA4 was barred from caring for Resident 5 based on his preference. Despite this, LVN2 and other staff referenced confusion or incomplete awareness about which residents CNA4 could not be assigned to, and CNA4 herself stated that Resident 5 did not want her to care for him and that she was aware she was not allowed to have Resident 5. These events demonstrate that the facility did not consistently ensure that staff assignments and care practices honored residents’ expressed preferences and protected them from alleged abusive or disrespectful interactions, as required by the facility’s abuse prevention and rules of conduct policies. In addition, multiple staff interviews revealed inconsistent understanding and communication regarding restrictions on CNA4’s assignments. LVN2 believed only Resident 5 could not be assigned to CNA4, while RN1 later learned from CNA4 that she was not supposed to be assigned to Resident 4. LVN3 stated she was unaware that CNA4 could not be assigned to Resident 4 until after the altercation, and also stated that CNA4 was not allowed to have Resident 5. The Social Services Director knew that CNA4 had been removed from caring for Resident 5 but did not know the reason or how Resident 5 developed bruising on his arm and fingers. The Administrator stated that if a resident does not want a staff member to care for them, staff should honor the resident’s request, and expressed concern about CNA4’s code of conduct and its effect on other residents. These facts collectively show that the facility failed to ensure that CNA4 was not assigned to residents who had requested not to receive care from her and failed to prevent situations that escalated into loud arguments and possible physical altercations, contrary to the facility’s abuse prevention and conduct policies.
Failure to Maintain Adequate Nursing and CNA Staffing Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents' needs in accordance with its own staffing policy on multiple sampled days. Review of the facility’s Direct Care Services Hours Per Patient Day (DHPPD) records showed that on seven of ten sampled days, total nursing and CNA hours fell below the facility’s stated minimums of 3.5 total nursing DHPPD and 2.4 CNA DHPPD, absent any waiver. On one morning shift, the DON confirmed there were only five CNAs assigned to care for 79 residents on the skilled unit. The DON acknowledged the facility was experiencing staffing shortages and that adequate staffing is needed to ensure staff can provide care and services to residents. A resident admitted with hemiplegia and hemiparesis affecting the right dominant side, epilepsy, and muscle weakness, and assessed as cognitively intact and requiring moderate to extensive assistance with ADLs, reported that when he requested showers on his scheduled shower days, staff told him his shower would be delayed until the afternoon because the facility did not have enough staff. A CNA interviewed on the same day stated she was unable to provide this resident’s shower due to short staffing. The CNA also reported that when residents have private caregivers, the facility allows those caregivers to perform CNA responsibilities such as feeding, repositioning, changing, and cleaning residents to ease staff workload.
Failure to Implement Scabies Prevention and Control Measures
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policy and procedures for scabies when a resident exhibited signs and symptoms consistent with scabies. The resident, who had diagnoses including toxic encephalopathy, ESRD, and type II DM, was cognitively intact and required only setup or clean-up assistance for ADLs. Physician progress notes documented that the resident had significant itching and had been treated multiple times with permethrin and ivermectin for suspected scabies, including during a recent hospitalization. An SBAR dated 1/30/2026 described an unknown generalized skin condition with generalized redness and rash on the body and complaints of itching, with a recommendation for permethrin 5% weekly for four weeks. Despite these ongoing symptoms and repeated treatments for suspected scabies, the facility did not perform diagnostic testing as outlined in its policy. The infection preventionist stated that scabies diagnosis requires skin scrapings sent to a lab, but confirmed that no skin scraping had been done on this resident to diagnose and identify scabies. The resident continued to have diffuse scattered excoriations and generalized rash, with staff describing numerous scratches on the trunk and extremities, red scattered skin rash, and constant scratching. These findings were documented in the medical record and confirmed in staff interviews. The facility also failed to carry out required contact identification and education measures specified in its scabies prevention and control policy. The policy required that as soon as a possible case of scabies is identified, the infection control practitioner develop a contact identification list for all residents, staff, visitors, and volunteers who may have had direct physical contact with the case within the previous month, and to notify and educate employees, family members, and visitors. The infection preventionist acknowledged that no contact list had been started or developed for this resident and that no education or in-services regarding scabies had been provided to staff. These omissions occurred despite the infection preventionist’s acknowledgment that the resident had signs and symptoms of scabies and that scabies is contagious and passed through contact.
Failure to Maintain Resident Rooms Free of Ongoing Water Leaks
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment by not ensuring that multiple resident rooms were free of water leaks, contrary to its Physical Environment and General Maintenance policies. In one room, a resident with spinal stenosis, polyneuropathy, and type II DM, who had mildly impaired cognition and required moderate to maximal assistance with ADLs, reported feeling water dripping from the ceiling beginning the previous day. Surveyors observed a concentric ring and water bubble on the ceiling, with the resident’s bed moved to the middle of the room to avoid getting wet, and towels, blankets, and a basin placed on the floor to collect water from the ceiling. In another room, a resident with hemiplegia and hemiparesis affecting the right dominant side, epilepsy, and muscle weakness, who required moderate to clean-up assistance with ADLs, was observed with water actively dripping from the ceiling. The ceiling showed rusty brown discoloration, and a basin, blankets, and towels were on the floor to catch the water. The Maintenance Director acknowledged that the roof had been repaired previously but that water leaks persisted, especially after rain, and described a bubble dent and water stains on one room’s ceiling and water intrusion through a window that required towels and blankets to block incoming water. The DON stated that water leaks and water on the floor put residents at risk of injury and acknowledged that residents should have been moved to provide a safe environment.
Failure to Reposition Resident, Complete Skin Assessment, and Correctly Set LAL Mattress for Pressure Ulcer Management
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards and its own policies for a resident with multiple Stage 4 pressure ulcers. The resident had diagnoses including malignant melanoma of the left upper limb and shoulder, Stage 4 pressure ulcers of the left buttock and sacral region, metabolic encephalopathy, and dementia, and required total dependence for ADLs per the MDS. A wound care provider documented physician instructions for offloading and repositioning throughout 24 hours, including at night, using wedges for support and frequent incontinence garment changes to prevent moisture-associated skin damage. The resident’s care plan for risk of impaired skin integrity specified goals to prevent further skin breakdown with interventions including turning and repositioning every two hours and more frequently if needed, use of an appropriate pressure-reducing mattress, and frequent incontinence pad changes. An IDT meeting with the resident’s POA documented that the plan of care included ensuring the resident would be turned and repositioned as scheduled and as needed, side to side only, to keep pressure off the sacral open area. Despite these documented plans and orders, the facility’s own records showed that the resident was not repositioned according to the every-two-hour schedule. Review of the ADL turn and repositioning log for nearly a one‑month period showed the resident was turned only two to three times per day, rather than every two hours as required by the care plan and IDT decisions. Interviews with the resident’s private caregiver and a CNA confirmed that the private caregiver was performing most of the resident’s ADLs, including turning, repositioning, feeding, and changing incontinent briefs, with CNAs assisting only at times. The DON acknowledged that CNAs and staff are responsible for ADL care and confirmed that the log documented turning only two to three times per day instead of every two hours. Facility policies on Prevention of Pressure Ulcers/Injuries and Activities of Daily Living required residents in bed to be repositioned at least every two hours and CNAs to turn and reposition residents at least every two hours, which was not reflected in the documentation for this resident. The facility also failed to complete and document required skin and pressure ulcer risk assessments upon the resident’s readmission, contrary to its Admission Assessment – Nursing policy and its Pressure Ulcer/Injury Management policy. The DON and treatment nurse both stated that residents’ skin must be assessed, evaluated, and documented on admission and readmission, and that the absence of documentation meant the assessment was not done. Additionally, the facility did not ensure the low air loss (LAL) mattress was set according to the resident’s weight, as required by the physician’s order for an alternating pressure mattress and the facility’s Low Air Loss Mattress policy. The resident’s weight was documented as 158 lbs and later 156 lbs, but observation showed the LAL mattress control set to firm at 250 lbs. The treatment nurse and DON both stated that the LAL mattress setting should correspond to the resident’s weight and that an incorrect setting would not assist with wound prevention and management. These failures in repositioning, admission skin assessment, and proper LAL mattress setup constituted the deficient practices identified by the surveyors.
Failure to Accurately Assess Fall Risk and Complete Post-Fall Neuro Checks
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at risk for falls was properly assessed and monitored after fall events, in accordance with its own fall-related policies and procedures. Resident 8 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, abnormalities of gait and mobility, and a history of falling. An MDS dated 1/15/2026 documented mildly impaired cognitive skills for daily decisions and a need for moderate to supervision assistance with ADLs, as well as use of a manual wheelchair. The resident’s fall risk care plan, initiated on 7/17/2025, identified problems and concerns related to falls and potential for injury due to balance issues, cognitive and physical impairment, generalized weakness, lack of coordination, and hemiparesis/hemiplegia, with interventions such as maintaining a hazard-free environment, keeping the call light and frequently used items within reach, and providing assistance with transfers. The facility’s fall risk evaluations for Resident 8 showed inconsistent and inaccurate scoring relative to the resident’s condition and history. A fall risk evaluation dated 10/22/2019 showed a high fall risk score of 11, while the evaluation dated 1/16/2026 showed a moderate fall risk score of 8, and the evaluation dated 2/17/2026 again showed a high fall risk score of 13. During interview and record review, RN 1 acknowledged that the 1/16/2026 fall risk evaluation was not accurately documented: the item for history of falls in the past three months was scored as 0 (no falls), despite facility records indicating a history of falls, and the gait/balance section was left blank instead of reflecting multiple balance and gait problems and the need for assistive devices. These inaccuracies meant the documented fall risk score did not accurately reflect the resident’s true fall risk status. The facility also failed to complete and document required 72-hour post-fall neurological checks after Resident 8 slipped out of the wheelchair during a transfer on 1/16/2026 and was later found on the floor on 2/17/2026. Review of the 72-hour neuro check documentation showed that post-fall neuro assessments were only recorded on 1/17/2026 during the 7 a.m.–3 p.m. shift and on 1/19/2026 during the 11 p.m.–7 a.m. shift, with no neuro checks documented on the evening and night shifts of 1/16/2026, the evening and night shifts of 1/17/2026, or on any shift on 1/18/2026. RN 1 stated that, per facility practice, residents must be checked by licensed nurses on all three shifts for 72 hours after a fall, and the DON confirmed there were inconsistencies and incomplete documentation of the post-fall assessments and fall risk evaluations. These actions and omissions constituted a failure to follow the facility’s policies titled “Falls by a Resident” and “Fall Risk & Prevention of Injury to include pathological Fractures,” which require complete post-fall assessments, incident investigations, and accurate fall risk assessments to guide care planning.
Failure to Notify Physician and Implement Elopement Precautions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its Change of Condition – SBAR policy and its Wandering/Exit Seeking Behavior policy for a newly admitted resident with severe dementia, depression, and psychoactive substance abuse. The resident had been hospitalized for failure to thrive, significant weight loss, and psychostimulant use disorder, and was documented as lacking capacity to make decisions. On admission, an elopement risk assessment scored the resident at 24, which the facility defined as high risk for elopement. Facility policy and the Registered Nurse Supervisor’s interview indicated that such abnormal findings required physician notification to obtain orders for a wander guard, but the physician was not informed and no wander guard order was obtained. On the day of admission, staff documented and observed multiple episodes of exit-seeking behavior. The visual hourly check log, initiated that afternoon, recorded that the resident attempted to exit the building several times in the evening and overnight, and that staff redirected and returned the resident to his room on at least three occasions. Nursing progress notes described the resident walking the hallway looking for an exit, expressing a desire to leave because he wanted to “live his life to the fullest,” and being difficult to redirect. Despite these repeated behaviors and the high elopement risk score, there is no documentation that the physician was notified or that elopement precautions requiring a physician order, such as a wander guard, were implemented. In the early morning hours following these events, the visual check log showed that at 4 a.m. the resident was no longer in his room. A CNA reported that the resident had been asleep around 1 a.m. and was still asleep when the CNA left for break at 3:30 a.m., but when the CNA checked again at approximately 4:20 a.m., the resident could not be found in his room or elsewhere in the facility. The resident’s family member reported having previously asked during a facility tour about residents’ ability to get out and was told there would be door monitoring and alarms. The family member later received a call from the facility stating the resident was missing, and then a call from police that the resident had been located in another city with bruises and scratches, with the resident stating he had fallen. The DON confirmed that once a resident is identified as an elopement risk, protocol including staff alerting and wander guard placement with a physician order should be initiated as soon as possible, which did not occur in this case.
Failure to Care Plan for High Elopement Risk Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized, comprehensive care plan addressing elopement risk for a newly admitted resident who had been clearly identified as high risk for elopement. The resident was admitted with diagnoses including dementia with behavioral disturbance, depression, and psychoactive substance abuse, and preadmission information from a general acute care hospital documented severe dementia, lack of decision-making capacity, failure to thrive, significant weight loss, and psychostimulant use disorder. An elopement risk assessment completed at admission scored the resident at 24, which the facility defined as high risk (17 or higher), and the facility’s policies required that such findings be incorporated into a baseline and comprehensive care plan with measurable objectives and interventions, including care plan interventions for wandering/exit-seeking behavior. Despite this high-risk assessment and the facility’s written policies, no elopement risk care plan was developed for the resident, and the physician was not notified to obtain an order for a wander guard. Nursing documentation and visual hourly check logs from the evening and night of admission showed multiple episodes of exit-seeking behavior: the resident attempted to exit the building several times in the west hallway and was redirected back to the room at 7 p.m., 9 p.m., and 1 a.m. A nursing progress note described the resident walking the hallway looking for an exit, expressing a desire to leave because he wanted to “live his life to the fullest,” and being difficult to redirect. CNA interview confirmed that exit-seeking behavior began after dinner, that the resident became upset when redirected back to his room, and that the resident was last observed asleep around 1 a.m. By 4 a.m., staff discovered the resident was no longer in the room or anywhere in the facility, and the resident’s whereabouts were unknown for an extended period. The resident’s family member reported having previously asked during a facility tour whether residents could get out and was told there was someone at the door during the day and that the door was locked and alarmed at night. The family member stated that on admission day, the resident had repeatedly asked to go home and needed reminders to stay. The family member later received notification from the facility that the resident was missing and subsequently from police that the resident had been located in another city with bruises and scratches, and the resident reported having fallen. Facility leadership and the RN supervisor acknowledged in interviews that the resident had been assessed as a high elopement risk, that the physician was not informed, and that an elopement care plan and related interventions were not initiated as required by facility policy, which could have prevented the resident from leaving the facility without staff knowledge.
Failure to Follow Self-Administration Determination and Complete Wound/Catheter Treatments and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of quality in medication/treatment administration and documentation for two residents. For Resident 1, the Self-Administration of Drugs Assessment, completed by the IDT, indicated it was not safe for the resident to self-administer drugs. Despite this, Treatment Nurse 1 reported that the resident was performing his own suprapubic catheter flushes, and she documented the ordered daily flushes as completed on the Treatment Administration Record (TAR) even though she did not perform them and had never observed the resident doing them. The TAR for Resident 1 also showed blank entries, without any notation of refusal or other explanation, for ordered treatments including suprapubic catheter care and left ischium wound care on multiple dates. Resident 1’s clinical information showed he had neuromuscular dysfunction of the bladder, HTN, atrial fibrillation, an indwelling suprapubic catheter, and required moderate to maximal assistance with ADLs, while his MDS indicated intact cognitive skills for daily decisions. He reported that on one day he did not receive any of his daily skin treatments because there was no treatment nurse available, and he stated that his suprapubic catheter required daily care. Treatment Nurse 1 acknowledged that on one of the cited dates she did not provide any skin treatment because the resident refused suprapubic catheter care, yet this refusal and the missed treatments were not documented on the TAR. She further acknowledged that she signed for treatments as if she had administered them on multiple dates when she had not. For Resident 2, who had diagnoses including neuromuscular dysfunction of the bladder, HTN, and atrial fibrillation, and required moderate to maximal assistance with ADLs, the physician’s orders included daily sacrococcyx wound care with NS, medihoney, and dry dressing, and daily topical ketoconazole cream to the right lower back. Review of Resident 2’s TAR showed multiple blank entries for these ordered treatments on several dates, with no documentation of completion, refusal, or any reason for the omissions. Registered Nurse 1 confirmed that a blank TAR entry with no notation means the treatment was not done and that the correct process is to document why a treatment was not completed rather than leaving the TAR blank. Facility policies on self-administration of medications and prevention of pressure ulcers/skin care required IDT determination of self-administration safety and detailed documentation of skin care, refusals, and resident condition, which were not followed in these cases.
Failure to Obtain Proper Informed Consent for Vaccinations
Penalty
Summary
Facility staff failed to obtain proper informed consent for COVID-19 and influenza vaccinations for a resident with cognitive impairment. The resident, who had diagnoses including schizophrenia and was documented as lacking capacity for medical decision-making, was recorded as having verbally declined both vaccinations. However, according to the facility's policy and the Director of Nursing, residents without decision-making capacity should not be providing consent or declination themselves; instead, consent or declination should be obtained from the resident's representative or family member. Record reviews showed that the resident's medical history and assessments indicated impaired cognition and mental incapacitation. Despite this, the facility documented the resident's own verbal declination for both vaccines, rather than obtaining the required authorization from a representative. The facility's policy requires that informed consent or declination for vaccinations be obtained from the appropriate decision-maker and properly documented, which was not followed in this case.
Failure to Adhere to Infection Control Practices and Documentation
Penalty
Summary
The facility failed to ensure adherence to infection prevention and control practices in several key areas. Four out of five sampled residents did not receive COVID-19, pneumonia, and influenza vaccines as required, despite some having provided verbal consent for vaccination. Documentation was lacking in the residents' medical records to confirm administration of these vaccines, and there was no evidence of consent or declination for the pneumonia vaccine. The Director of Nursing confirmed that there was no documentation in the electronic or physical charts to show that the vaccines were administered, and was unsure why the vaccinations were not given even when consent was obtained. Staff members, including two CNAs and an LVN, were observed not adhering to proper infection control protocols. One CNA entered a COVID isolation room without performing hand hygiene and without donning the required PPE, aside from an N95 mask. This CNA also improperly handled contaminated linen by carrying it into the hallway instead of placing it in the designated hamper inside the isolation room. Both the CNA and LVN admitted to not being fit tested for the N95 masks they were wearing, and the facility's fit testing binder lacked current documentation for these staff members. The Director of Nursing acknowledged that fit testing should be conducted annually and upon hire, but records were incomplete or outdated. Housekeeping practices were also found deficient, as high-touch surfaces such as handrails were not consistently documented as being disinfected according to the facility's COVID-19 Mitigation Plan, which requires cleaning at least every four hours. The janitor stated that while disinfection occurred twice per shift, there was no log or documented evidence to verify this. The Director of Nursing was unable to confirm the frequency of disinfection or the existence of a tracking log, despite facility policy requiring such documentation. These lapses in infection control practices were observed and confirmed through interviews, record reviews, and direct observation.
Failure to Follow Infection Control Protocols During Linen Handling
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed carrying clean towels, linen, a gown, and chux pads when a towel slipped from their hand and fell onto the floor. The CNA picked up the towel, mixed it with the remaining clean items, and proceeded toward a resident's room with the intention of using the contaminated towel on the resident. The incident was witnessed by a surveyor, and the CNA acknowledged that the towel had been on the floor and was about to be used for resident care, which is a violation of infection prevention protocols and facility policy. The contaminated items were subsequently discarded after the CNA was confronted. The resident involved had a complex medical history, including acute respiratory failure with hypoxia, a benign neoplasm of the meninges, acute kidney failure, and a tracheostomy. Interviews with facility staff, including a Licensed Vocational Nurse and the Infection Prevention Nurse, confirmed that using linen that had been on the floor poses a risk of infection, especially for immunocompromised residents. The facility's infection control policy specifies that any linen that comes into contact with the floor should be treated as contaminated and not used for resident care.
Failure to Provide Timely Ophthalmology Services for Resident with Ongoing Eye Symptoms
Penalty
Summary
The facility failed to ensure that a resident with a history of type 2 diabetes and essential hypertension received appropriate ophthalmology services as required by physician orders, resident preferences, and facility policy. The resident, who was moderately cognitively impaired and required maximum assistance with activities of daily living, experienced untreated bilateral itchy and discolored eyes since admission. Multiple staff members, including a CNA and LVN, observed the resident rubbing her eyes and noted discoloration but did not report these symptoms to nursing or medical staff. A family member also reported the resident's ongoing eye issues to a charge nurse, but there was no evidence that this concern was communicated to a physician or resulted in an ophthalmology referral. Record reviews confirmed that there were no active orders for ophthalmology services for the resident, and no documentation indicated that the resident had been seen by an eye doctor since admission. The Director of Social Services and DON both acknowledged that the resident had not been scheduled for or received eye care in accordance with facility policy, which required eye doctor visits every 3-6 months and as needed. The ophthalmologist confirmed that he had not been notified of the resident's symptoms and only conducted annual visits. The administrator stated that residents are seen by the ophthalmologist based on need, but also indicated there was no formal policy for eye or vision care in place.
Failure to Notify Family of Resident Room Changes
Penalty
Summary
The facility failed to notify a resident's family member when the resident was moved to different rooms on two consecutive days. The resident, who had severe cognitive impairment and was totally dependent on staff for activities of daily living, was transferred without the knowledge or consent of her family member. The family member reported not being informed or consulted about the room changes, which resulted in the resident being placed in a three-bed room with limited space, making it difficult to use necessary equipment such as a Hoyer Lift and leaving the resident without a bedside table for personal belongings. Interviews and record reviews confirmed that there was no documentation of family notification regarding the room changes, as required by the facility's policies and procedures. The Social Services Director acknowledged that the facility is responsible for notifying family members or representatives of room transfers and confirmed that this did not occur in this instance. The facility's policies also require documentation of the room transfer and communication with the resident and their representatives, which was not completed.
Failure to Protect Resident Property Resulting in Loss of Hearing Aid
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal property, specifically a cochlear hearing aid. The resident, who had severe bilateral hearing loss and a history of cochlear implant surgery, was cognitively impaired and fully dependent on staff for activities of daily living. Upon admission, the resident's hearing aid and charger were documented in the inventory list. The resident's family member reported the hearing aid missing after being unable to locate it in the resident's room and notified facility staff and management. Despite this report, the hearing aid was not replaced, and communication with the resident became difficult for the family member. Interviews and record reviews revealed that the Social Services Director was aware of the missing hearing aid and stated that an investigation and replacement process was underway. However, there was no evidence in the medical record that a theft and loss report had been filed as required by facility policy. The policy mandates prompt and thorough investigation of all reports of theft or misappropriation, including interviews and searches, but these steps were not documented as completed for this incident.
Failure to Develop Comprehensive Care Plan for Tube-Pulling Behaviors
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive care plan addressing a resident's behavior of removing hand mittens and pulling on their tracheostomy and gastrostomy (g-tube) tubes. The resident, who had diagnoses including respiratory failure, ventilator dependence, type II diabetes mellitus, and anxiety, was assessed as having severely impaired cognitive skills and was dependent on staff for activities of daily living. Nursing notes documented the use of bilateral hand mittens to prevent the resident from pulling out their tracheostomy and g-tube, and there was a documented incident where the g-tube became dislodged after the resident pulled on it, requiring replacement. Despite these documented behaviors and interventions, a review of the resident's care plan revealed that it did not address the behavior of removing mittens or pulling on the tracheostomy and g-tube. Staff interviews confirmed the ongoing issue, with reports of the resident removing mittens multiple times in a shift and the need for frequent reapplication. The facility's policy required a comprehensive, resident-centered care plan with measurable objectives and timeframes for all identified needs, but this was not implemented for the resident's specific behaviors.
Failure to Follow Physician Orders for Blood Sugar Monitoring and Post-Death Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with multiple complex medical conditions, including respiratory failure, ventilator dependence, and type II diabetes mellitus. Specifically, the resident's physician ordered finger stick blood sugar (FSBS) monitoring every 12 hours at 6 a.m. and 6 p.m., with insulin administration as needed per a sliding scale. However, a nurse performed the blood sugar check at 12 p.m., not at the times specified in the physician's order, and did not administer insulin, citing nursing judgment due to the resident being on tube feeding. This deviation from the prescribed monitoring schedule was confirmed by both the nurse involved and a reviewing RN, who noted that the physician's order was not followed and there was no clinical indication for an unscheduled blood sugar check. Additionally, the facility did not follow its own policy and procedure regarding documentation after a resident's death. When the resident expired, there was no death certificate on file in the medical record, and the attending physician had not documented the cause of death in the progress notes as required. The facility's policy mandates that the attending physician must record the cause of death and complete and file a death certificate within 24 hours or as prescribed by state law, but this was not done.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident who had multiple traumatic injuries, including fractures and recent bladder surgery. The resident was prescribed hydromorphone for moderate to severe pain, with orders to administer the medication as needed and to assess and document pain levels before and after administration. Despite these orders, the resident repeatedly reported severe pain and did not receive timely administration of hydromorphone. On several occasions, the medication was not available, and staff did not access the emergency medication kit promptly or document pain assessments and follow-up evaluations as required by facility policy. Record reviews revealed gaps in pain assessment documentation and medication administration. The resident's pain flow sheets and medication administration records showed missing entries for pain levels and interventions on multiple days, and there was no evidence of reassessment of pain within two hours after medication was given. Interviews with nursing staff indicated confusion about procedures for accessing the emergency medication kit and delays in obtaining pharmacy authorization, resulting in the resident experiencing prolonged periods of uncontrolled pain. The pharmacy confirmed that the emergency kit was stocked and that authorizations were provided when requested, but there were no calls from the facility on certain dates when the resident reported pain. The resident described experiencing significant pain over a weekend, repeatedly requesting pain medication, and being told to wait due to unavailability of hydromorphone. The resident ultimately required transfer to an acute care hospital for severe pain and hematuria. Staff interviews corroborated the resident's account of delayed pain management and lack of timely medication administration. Facility policy required prompt assessment, medication administration, and physician notification for unrelieved pain, but these procedures were not consistently followed, resulting in the resident suffering from uncontrolled pain.
Resident Exposed During Incontinence Care Due to Failure to Maintain Privacy
Penalty
Summary
A certified nursing assistant (CNA) failed to maintain a resident's dignity and privacy during incontinence care. The CNA was observed changing the resident's incontinence diaper in a shared room with the privacy curtain open, leaving the resident's private areas completely exposed. The CNA was unable to explain the importance of keeping the privacy curtain closed during personal care and responded in a confrontational manner when questioned by the surveyor. A licensed vocational nurse (LVN) was present and confirmed the observation and interview. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living, and had diagnoses including dementia, hypertension, and dysphagia. Facility policy and procedures reviewed indicated that all residents are to be treated with dignity and respect at all times, and that privacy must be maintained during personal care. The actions observed were not in accordance with these policies.
Failure to Ensure Staff Competency in Medication Administration and Resident Privacy
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to demonstrate the necessary skills and knowledge to safely prepare and administer medications for a resident with schizophrenia, hypertension, and dysphagia. The LVN crushed all of the resident's morning medications and mixed them together in applesauce without a physician's order to do so. The LVN was unable to identify the medications being administered, did not verify the resident's identity, and admitted to not reviewing the physician's orders prior to administration. The Registered Nurse Supervisor confirmed that there was no order to crush the medications and that the LVN did not follow proper procedures for medication administration, including not crushing medications together and not ensuring the resident was present during preparation. A Certified Nursing Assistant (CNA) failed to provide care with dignity and respect to a resident with dementia, hypertension, and dysphagia who was dependent for activities of daily living. The CNA was observed changing the resident's incontinence diaper in a shared room with the privacy curtain open, leaving the resident's private areas exposed. The CNA was unable to explain the importance of maintaining privacy during personal care and responded inappropriately when questioned about the procedure. Another nurse present confirmed that privacy should have been maintained during the care activity. The facility's policies and procedures require that nursing staff participate in competency-based training and demonstrate skills necessary to meet residents' needs, including medication management and respecting resident rights. The observed actions of the LVN and CNA were not consistent with these requirements, as both failed to follow established protocols for safe medication administration and resident privacy.
Failure to Follow Safe Medication Administration Procedures
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow proper medication administration procedures for a resident with schizophrenia, hypertension, and dysphagia, who also had moderate cognitive impairment and lacked capacity for medical decision-making. The LVN prepared the resident's morning medications without properly identifying the resident, as the resident was not present during medication preparation and the LVN was unable to confirm the resident's location or identity at the time. The LVN removed medications from multiple bubble packs, placed them in a cup, and subsequently crushed three tablets and opened a capsule, mixing all the medications together in applesauce. This was done without a physician's order to crush the medications, and the LVN was unable to verbalize which medications were being administered or the reasons for not crushing certain medications together. The LVN admitted to not reviewing physician orders or verifying the medications with the resident prior to administration. The Registered Nurse Supervisor confirmed that there was no physician's order to crush the medications and that the LVN did not follow required procedures for resident identification, medication verification, or safe medication administration. Facility policies reviewed indicated that medications should only be crushed if ordered, residents must be identified before administration, and medications should be administered at the time they are prepared, none of which were followed in this instance.
Failure to Document Staff Identification on Medication Administration Records
Penalty
Summary
Licensed nursing staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for three of four sampled residents. Specifically, the Medication Administration Records (MARs) for these residents were missing the required initials and signatures of the licensed staff responsible for administering medications. This omission was observed throughout the month of April for multiple medications, with only a few exceptions where staff signatures or initials were present. Resident 1, who was admitted with diagnoses including hypertension and end stage renal disease, had a MAR for Apixaban administration that lacked staff identification for nearly the entire month. Resident 2, admitted with type two diabetes mellitus, hypertension, and benign prostatic hyperplasia, had MARs for Aspirin and Flomax that also lacked staff initials and signatures for the documented administration dates. Resident 3, with a history of transient ischemic attack, peripheral vascular disease, and glaucoma, had MARs for Dorzolamide-Timolol and Losartan Potassium that were missing staff identification for most of the month, except for one date. During interviews and record reviews, multiple nursing staff, including RNs and LVNs, acknowledged the deficiency and confirmed that it is standard practice to document initials and signatures on the MAR after medication administration. The interim DON also confirmed that the MARs were missing identifiable information for the responsible licensed staff, which is not in accordance with standard practice. The facility's policy and procedures require that orders and documentation be consistent with principles of safe and effective order writing, including the use of approved abbreviations and symbols.
Ceiling Leak and Cluttered Environment in Resident Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in room [ROOM NUMBER], which was occupied by three beds, with one resident present. Observations during an initial tour revealed that beds and floors were covered with blankets to absorb water leaking from the ceiling. Interviews with the resident and staff confirmed that the ceiling had been leaking for a couple of months, particularly during rain, and that the facility was still in the process of identifying and fixing the issue. The presence of blankets and basins to capture water leaks created a cluttered and disorderly environment, posing potential risks for accidents. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) indicated that the water leak had been ongoing, and staff had been using blankets and buckets to manage the situation. The facility Administrator acknowledged the potential hazards for falls and accidents due to the clutter and water leak. A subsequent record review revealed that the skylight glass frame causing the leak had been repaired, and inspections during recent rainstorms confirmed that the problem had been resolved. However, the facility's policy and procedures emphasized the importance of maintaining a safe, clean, and comfortable environment, which was not upheld in this instance.
Case Manager's Inaccessibility Delays Admissions
Penalty
Summary
The facility failed to ensure that the Case Manager (CM) possessed the necessary competencies and skills to facilitate a seamless and efficient admission process, as outlined in the facility's Nurse Admission Policy. The deficiency was identified through observations, interviews, and record reviews. The Business Office Manager (BOM) explained that referrals for new admissions are sent from hospitals and initially reviewed by the CM, who works remotely out of state. During the surveyor's on-site visit, multiple attempts to contact the CM via telephone were unsuccessful, as the calls went directly to a full voicemail box. The CM acknowledged that when his voicemail box is full, it prevents people from contacting him, which in turn delays the admission process for residents needing to be admitted to the facility. The facility's policy requires the CM to collaborate with hospital case managers and serve as a liaison to ensure all necessary information is obtained for admission approval. The inability to reach the CM and the resulting delays in the admission process negatively impacted the residents' plan of care and the delivery of necessary care and services.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to implement its abuse policy and procedures by not reporting an alleged abuse incident involving a resident to the California Department of Public Health. The incident involved a resident with severe cognitive impairment who was dependent on staff for all activities of daily living. The alleged abuse was observed by a Licensed Vocational Nurse (LVN) who reported that another resident was rubbing the impaired resident's left arm and inner thigh close to the groin, which the LVN considered to be sexual abuse. However, the Registered Nurse Supervisor (RNS) did not classify the incident as sexual abuse but acknowledged that allegations of abuse must be reported to law enforcement, the ombudsman, and the Department of Public Health. The Facility Administrator (FA) admitted that the abuse allegation had not been reported to the Department of Public Health, although the police had been contacted. The facility's policy and procedure on abuse prevention and reporting require that any suspected abuse be reported immediately to the appropriate authorities. The failure to report the incident to the Department of Public Health resulted in a delay of the onsite investigation by the State Agency, potentially exposing the resident to further abuse and causing mental anguish and emotional distress.
Failure to Return and Protect Residents' Clothing
Penalty
Summary
The facility failed to ensure that residents received their clothes back in the correct number and color after laundering, and that residents did not wear other residents' clothes. This deficiency was observed in two residents, Resident 21 and Resident 101. Resident 21 reported that he sent his clothes to the facility's laundry and did not receive them back. His clothes were labeled with his name, but despite asking several staff members, he did not recover them. Resident 101 also reported missing clothes and noted that one of her T-shirts was bleached from black to beige. Additionally, she observed another resident wearing one of her T-shirts. Interviews with staff revealed that clothes are supposed to be labeled and placed in a mesh bag before being sent to the laundry. If clothes are lost, the CNA on duty is expected to search the laundry room and report the loss to the Social Services Director (SSD) if they cannot be found. However, the SSD was not aware of the missing or damaged clothes for Residents 21 and 101 until the issue was brought to her attention. The facility's policy requires a thorough investigation of theft or misappropriation of resident property, but this process was not initiated until after the residents reported their grievances. The facility's administrator stated that an inventory list is maintained for residents' belongings, and any new items brought in after admission should be logged by staff. If items are lost or stolen, the facility is responsible for replacing them after a search. However, the initial response to the residents' grievances was inadequate, as the SSD was unaware of the issue, and the facility's grievance policy was not effectively implemented to address the residents' concerns promptly.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents, Resident 34 and Resident 69, during meal assistance. For Resident 34, who has severe cognitive impairment due to dementia and is g-tube dependent, a Certified Nursing Assistant (CNA) was observed standing over her while assisting with feeding. This required Resident 34 to extend her neck to look up at the CNA, which is against the facility's policy that staff should be seated at eye level with residents during meal assistance to promote dignity. Resident 69, who is visually impaired and has intact cognition, was not provided with a description of the food items or their placement on the tray during meal service. The CNA assisting Resident 69 did not describe the food layout, assuming the resident's independence in eating. The facility's policy requires staff to describe the food items and their location to visually impaired residents to accommodate their needs and maintain their dignity.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to protect a resident's privacy by not closing the privacy curtain while performing personal care. This incident involved a resident who was visually exposed to their roommates during morning care. The resident's room window blinds were also open, allowing a clear view from the outside alley. CNA 1 acknowledged that the privacy curtain should have been closed to maintain the resident's privacy. The resident involved had a severely impaired cognition and was totally dependent on staff for all activities of daily living. The resident had a feeding tube, indwelling catheter, and two stage 4 pressure ulcers. The facility's policy and procedures emphasized the importance of maintaining privacy during personal care activities, which was not adhered to in this instance. The Director of Nursing confirmed that the privacy curtain should be closed during a resident's care to maintain dignity and privacy.
Facility Fails to Maintain Safe and Homelike Environment for Resident
Penalty
Summary
The facility failed to ensure a safe, comfortable, and clean homelike environment for Resident 101, as evidenced by a broken window frame and detached window glass in the resident's room. This deficiency allowed cold air to enter the room continuously, making the resident feel uncomfortably cold at night. The resident, who has Raynaud's syndrome, schizophrenia, and depression, expressed discomfort due to the cold temperatures and was ashamed of the living conditions. The Minimum Data Set (MDS) indicated that the resident's cognition was intact, and they required assistance with certain daily activities. Observations confirmed that the window in Resident 101's room would not close properly, and the glass was loose, separating from the window frame. The Maintenance Director acknowledged the disrepair and stated that the window would be fixed immediately. The facility's policy on providing a sanitary and homelike environment was not adhered to, as the room did not maintain comfortable and safe temperatures, and trash was observed on the floor, with the floor being only partially cleaned.
Failure to Develop Comprehensive Care Plan for Resident with Restraints
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 30, who was using physical restraints. Resident 30 was admitted with multiple diagnoses, including respiratory failure, epilepsy, and ventilator dependence, and had severely impaired cognition. The resident's Minimum Data Set indicated dependency on assistance for various activities of daily living and the use of limb restraints less than daily. Despite physician orders to apply hand mittens to prevent the resident from pulling at medical tubing, a care plan addressing the use of these restraints was not developed. Observations confirmed the resident was wearing hand mitten restraints, and interviews with facility staff, including a registered nurse and the Director of Nursing, revealed that a care plan should have been initiated to guide staff on interventions and goals for the resident. The facility's policy required care plans for residents in restraints to address immediate medical symptoms and underlying problems, as well as measures to reduce or eliminate the need for restraint use. The absence of a care plan for Resident 30's mitten restraints was acknowledged by the staff, indicating a lapse in the facility's adherence to its own policies and procedures.
Failure to Provide Prescribed Restorative Nursing Assistance
Penalty
Summary
The facility failed to provide the restorative nursing assistance program as per the physician's orders for a resident, resulting in a deficiency. The resident, who was admitted with conditions including hemiplegia, diabetes mellitus, and hypertension, was supposed to receive passive range of motion (PROM) therapy on their bilateral upper extremities three times a week. However, the restorative flow sheet for November 2024 showed that the therapy was not provided on nine days, including a week where it was only provided once instead of the prescribed three times. Interviews with the Restorative Nurse Assistant and the Registered Nurse Supervisor confirmed the lack of adherence to the physician's orders. The Director of Nursing acknowledged the need to follow the physician's orders and document the therapy sessions. The facility's policy on range of motion exercises emphasized the importance of planning, scheduling, and documenting passive ROM exercises, which was not adhered to in this case.
Failure to Prevent Fall in High-Risk Resident
Penalty
Summary
The facility failed to adequately identify, evaluate, and implement interventions to prevent falls for Resident 51, who was at high risk for falls. Despite having a care plan in place that included the use of a tab alarm, not leaving the resident unattended, and using a low bed and floor mat, Resident 51 experienced an unwitnessed fall. The resident's fall risk evaluation indicated a high risk for falls, and the care plan aimed to prevent injuries from falls. However, the interventions were not effectively implemented, leading to the resident's fall. Following the fall, Resident 51 was transferred to a general acute care hospital, where a CT scan revealed an acute on chronic right frontal convexity subdural hematoma with a midline shift. The resident was subsequently intubated due to altered mental status and admitted to the ICU for further care. The Director of Nursing acknowledged that the fall incident should have been reported per CDPH guidelines and facility policy, indicating a lapse in the facility's accident prevention procedures.
Failure to Label Tube Feeding Equipment
Penalty
Summary
The facility failed to label tube feeding equipment according to its policy and procedure for a resident, which had the potential to cause infection. The resident, who was admitted with diagnoses including dependence on a respiratory ventilator, dysphagia, and hypertension, was observed with a tube feeding bottle, water bag, and tubing hanging from the feeding pole without any labels. These labels should have included the resident's name, type of feeding formula, rate, time, and nurse's initials. This omission was confirmed during observations and interviews with the Licensed Vocational Nurse (LVN) and the Registered Nurse Supervisor (RNS), who both acknowledged the lack of labeling and its importance for infection control. The Director of Nursing (DON) further confirmed that the tube feeding set should have been labeled with specific information to ensure the correct formula is administered and to adhere to infection control practices. The facility's policy on enteral feeding, reviewed in July 2024, also required that the formula label document initials, date, and time the formula was hung, and that the label was checked against the order. The failure to follow these procedures was identified as a deficiency during the survey.
Inappropriate Storage of Staff Food in Kitchen Refrigerator
Penalty
Summary
The facility failed to ensure that outside staff food was not stored in the kitchen refrigerator, which is a violation of infection control protocols. During an observation in the kitchen, surveyors found a half-filled cup from an outside coffee shop, a can of carbonated soda, an open undated bag of tortillas, and an unlabeled plastic container of an unknown substance stored in the kitchen's top freezer refrigerator. These items were confirmed by a kitchen staff member to be personal food items and not intended for residents. The kitchen staff member acknowledged that these items should not have been stored in the kitchen refrigerator and proceeded to have them removed. Further interviews with the Dietary Supervisor and the Director of Nursing confirmed that staff food items should not be stored in the kitchen refrigerator due to infection control concerns. The facility's policy and procedures indicate that food brought by family or visitors should be labeled and stored separately from facility-prepared food, with perishable items stored in resealable containers with tightly fitting lids. The presence of staff food in the kitchen refrigerator was a breach of these procedures, potentially increasing the risk of foodborne illness among residents.
Infection Control Deficiencies in Hand Hygiene and Tube Feeding Labeling
Penalty
Summary
The facility failed to provide proper hand hygiene for Resident 69 before meals, which is a critical aspect of infection prevention and control. Resident 69, who was admitted with conditions including hyperlipidemia, encephalopathy, and hypertension, was observed eating with bare hands without washing them. Despite being independent in eating, the resident was not offered assistance with hand washing, which was confirmed by a Certified Nurse Assistant (CNA) who acknowledged the risk of bacterial spread due to this oversight. The Director of Nursing (DON) also confirmed that hand washing should have been facilitated to prevent infection. In another instance, the facility did not adhere to its policy for labeling tube feeding equipment for Resident 44, who was dependent on a respiratory ventilator and had cognitive impairment. During an observation, the tube feeding bottle, water bag, and tubing were found without labels indicating the resident's name, type of formula, rate, time, or nurse's initials. Both a Licensed Vocational Nurse (LVN) and a Registered Nurse Supervisor (RNS) confirmed the absence of labels, which are necessary for infection control and to ensure the correct administration of the feeding formula. The Director of Nursing reiterated the importance of labeling the tube feeding set to match physician orders and for infection control purposes. The facility's policy on enteral feeding requires that the formula label document the initials, date, and time the formula was hung, which was not followed in this case. These deficiencies in infection control practices had the potential to cause infection and cross-contamination for the residents involved.
Failure to Obtain Informed Consent for Influenza Vaccine
Penalty
Summary
The facility failed to obtain informed consent before administering an influenza vaccine to a resident, identified as Resident 41. The resident received the influenza vaccine on November 4, 2024, but the consent was only obtained on November 8, 2024, from the responsible party. This oversight violated the responsible party's right to be notified and make informed choices regarding the resident's medical treatment. The resident, who was admitted to the facility with Alzheimer's disease, pressure ulcers, and osteoarthritis, was cognitively impaired and dependent on staff for daily activities, necessitating informed consent from a medical decision-maker. During interviews, the Infection Preventionist Nurse confirmed that the vaccine was administered before obtaining consent, acknowledging that this practice removed the choice from the responsible party. The Director of Nursing also stated that informed consent should be obtained upon admission and before administering vaccinations to honor the resident's rights. The facility's policy required annual consent for vaccinations from patients or their medical decision-makers, which was not adhered to in this instance.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, despite being aware of ongoing inappropriate behavior. Resident 2 had been persistently asking Resident 1 to marry them for several months, which was known to the facility staff. This behavior was not adequately addressed, leading to an altercation on 10/20/2024, when Resident 2 sneezed on Resident 1's shoulder, causing Resident 1 to become upset. Resident 2 then hit Resident 1, escalating the situation. Resident 1, who has severe cognitive impairments due to dementia and other medical conditions, was unable to effectively communicate or manage the situation. The facility's records, including the Minimum Data Sheet and Physician Progress Notes, indicated that Resident 1 lacked the capacity for decision-making and was at risk for further decline. Despite these documented vulnerabilities, the facility did not take sufficient action to prevent the altercation or protect Resident 1 from Resident 2's persistent advances. Interviews with staff and residents revealed that the inappropriate behavior had been reported to the facility's administration, but no effective measures were taken to address the situation. The Activity Assistant and Certified Nurse's Aides were aware of Resident 2's repeated marriage proposals to Resident 1 and had informed the administration, yet the issue persisted. The facility's policies on behavior assessment and abuse prevention were not adequately followed, contributing to the failure to protect Resident 1 from abuse.
Failure to Address Resident Harassment and Abuse
Penalty
Summary
The facility failed to thoroughly investigate and address resident-to-resident physical abuse and harassment involving two residents. Resident 2 had been persistently asking Resident 1 to marry them for a couple of months, which was not appropriately addressed by the facility. This ongoing verbal harassment led to a physical altercation between the two residents on October 20, 2024. Resident 1, who was admitted with diagnoses including hemiplegia, dementia, lack of coordination, and glaucoma, was found to have severely impaired cognition and lacked the capacity to make decisions. Despite these vulnerabilities, the facility did not take adequate steps to protect Resident 1 from Resident 2's persistent proposals and verbal harassment. The facility's records and interviews revealed that staff members, including the Activity Director and Certified Nurse's Aide, were aware of Resident 2's behavior but failed to document or escalate the issue appropriately. Interviews with staff and residents indicated that Resident 2's behavior was known but not effectively managed. The Activity Director and other staff members reported the behavior to the Administrator, who did not recall being informed. The facility's policies on behavior assessment, abuse prevention, and change of condition were not followed, leading to a failure in protecting Resident 1 from ongoing harassment and eventual physical confrontation.
Failure to Conduct Rehabilitation Evaluation
Penalty
Summary
The facility failed to ensure that a rehabilitation services evaluation order for a resident was carried out. The resident, who was readmitted to the facility with acute respiratory failure, metabolic encephalopathy, and dependence on a ventilator, had a physician's order for a Physical Therapy (PT) and Occupational Therapy (OT) evaluation dated 10/7/24. However, during an interview with the Director of Rehabilitation on 10/24/24, it was confirmed that the resident was not receiving rehabilitation services. This was further corroborated by an email from the Medical Records Director on 10/29/24, which indicated that the resident was not under rehabilitation services, and thus, no records were available. The resident's Minimum Data Set (MDS) dated 10/9/24 showed severe cognitive impairment and dependency on staff for daily activities, highlighting the necessity of the ordered rehabilitation services. The Director of Nursing acknowledged during a telephone interview on 10/31/24 that not carrying out the PT/OT evaluation order could lead to the resident's functional decline. The facility's policy on Resident Mobility and Range of Motion, revised in 2017, states that residents should not experience an avoidable reduction in range of motion and should receive appropriate services to prevent further decline, which was not adhered to in this case.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent the elopement of a resident, identified as Resident 1, who left the facility unsupervised and without prior authorization. Resident 1, who had a history of leaving against medical advice, was admitted with diagnoses including metabolic encephalopathy, end-stage renal disease, and iron deficiency anemia. Despite being cognitively intact and able to walk without assistance, Resident 1 was at risk for elopement, as noted in their care plan. The care plan included interventions such as assessing elopement risks, obtaining elopement history from family, and placing the resident in an area where they could be easily supervised. On the day of the incident, Resident 1 was last documented by LVN 3 as being seen in the facility at various times, including after the time they had already left the facility. The facility's video footage showed Resident 1 leaving the facility through the front door without any staff present in the lobby/reception area. Interviews with staff, including LVN 3, CNA 1, and R1, revealed that Resident 1 was often seen sitting on the couch in the lobby area, but there was no consistent monitoring or documentation of their whereabouts. The receptionist, R1, left the desk unattended, allowing Resident 1 to leave unnoticed. The facility's policy and procedures required routine resident checks and documentation of these checks, but these were not adequately followed. Staff interviews indicated a lack of awareness of which residents were at risk for elopement and inconsistent documentation practices. The facility's video footage confirmed the absence of staff supervision at the time of Resident 1's elopement, highlighting a failure in implementing the necessary interventions to prevent such incidents.
Failure to Secure and Label Residents' Personal Foods
Penalty
Summary
The facility failed to monitor and secure residents' personal foods stored in a shared refrigerator, leading to potential issues of missing food and compromised infection control. Resident 1, who has intact cognitive skills and the capacity for medical decision-making, reported that food brought by his family went missing after being placed in the residents' refrigerator. During an observation, the refrigerator was found unlocked in the dining room/activity room, accessible to multiple residents, contrary to the facility's policy that it should be locked. Further inspection revealed multiple opened food items in the refrigerator without labels indicating when they were opened or when they should be discarded. The Dietary Supervisor confirmed that all foods brought by family or visitors should be labeled with the resident's name, the date it was brought in, and a use-by date. The Director of Nursing also stated that the refrigerator should be locked at all times and that food should be labeled to monitor residents' food properly. The facility's policy requires that food brought by family or visitors be stored in a manner distinguishable from facility-prepared food, with perishable items in resealable containers labeled with the resident's name and use-by date.
Failure to Conduct Regular Resident Council Meetings
Penalty
Summary
The facility failed to conduct Resident Council Meetings regularly, as required by their policy, which mandates meetings at least monthly. This deficiency was identified through interviews and record reviews, revealing that the meetings had not been held for several months. Resident 1, who has intact cognitive skills and values group activities, expressed concerns about the absence of these meetings, as he had unresolved issues regarding the residents' refrigerator. Similarly, Resident 4, the Resident Council President, confirmed the lack of meetings, which hindered the opportunity to address residents' concerns. The absence of an Activity Director (AD) contributed to the failure to hold these meetings, as the Activity Assistant (AA 1) stated they were not responsible for organizing the meetings and were unaware of the schedule. The Director of Nursing (DON) acknowledged that the AD is responsible for preparing the meetings and confirmed that no meeting minutes were available for August and September 2024. The facility's policy emphasizes the importance of these meetings for residents to discuss and make decisions about their living environment, highlighting the impact of the deficiency on residents' ability to voice their concerns.
Failure to Update POLST Leads to Conflicting Code Status
Penalty
Summary
The facility failed to ensure that a resident's clinical records were updated in accordance with the facility's policy and procedure, specifically regarding the Physician Orders for Life-Sustaining Treatment (POLST). The resident, who was admitted with diagnoses including heart failure and coronary artery disease, had a POLST indicating full code status, which conflicted with the physician's order and care plan that indicated a do not resuscitate (DNR) status. This discrepancy was identified during a review of the resident's records, which included the face sheet, history and physical, minimum data set, hospice agreement, and physician orders. The Director of Nursing (DON) confirmed the conflicting information between the POLST and the physician's order and care plan during an interview and record review. The facility's policy on advanced directives and hospice care planning emphasizes the importance of honoring residents' medical decisions and ensuring that care plans are appropriately coordinated between hospice and facility teams. The failure to update the resident's POLST to reflect their current wishes had the potential to cause conflict with the resident's healthcare preferences.
Failure to Implement Comprehensive Care Plan Due to Conflicting Code Status
Penalty
Summary
The facility failed to implement a comprehensive care plan that met the individual assessed needs of a resident, identified as Resident 2. The deficiency was identified during a review of Resident 2's records, which revealed conflicting information regarding the resident's code status. Resident 2 was admitted with diagnoses including heart failure and coronary artery disease and had the capacity to understand and make decisions. The Minimum Data Set indicated that Resident 2's cognitive skills for daily decision-making were intact. However, there was a discrepancy between the Physician's Orders, which indicated a DNR status, and the POLST, which indicated full code status. This inconsistency was confirmed during an interview with the Director of Nursing, who acknowledged the need to clarify the order with Hospice 1 and the physician. The facility's policy on Advanced Directives/POLST emphasizes the importance of honoring residents' medical decisions and ensuring that any changes in code status are properly documented and signed by a physician. Additionally, the policy on comprehensive person-centered care plans requires that care plans include measurable objectives and timetables to meet residents' needs. The failure to reconcile the conflicting information in Resident 2's care plan and POLST represents a deficiency in adhering to these policies, potentially impacting the resident's health and safety.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents, Resident 3 and Resident 4, were free from significant medication errors. For Resident 3, the facility did not administer medications on time as ordered by the physician. Resident 3, who had diagnoses including hypertension, diabetes mellitus, and respiratory failure, was supposed to receive medications such as lisinopril, methimazole, nifedipine, and folic acid at specific times. However, during a medication pass observation, it was noted that these medications were administered late due to the resident's physical therapy schedule. The Licensed Vocational Nurse (LVN) did not document the late administration or notify the physician about the elevated blood pressure, which was not in accordance with the facility's policy. Resident 4 also experienced a significant medication error when they did not receive their morning medications for three consecutive days. Resident 4, who had diagnoses including respiratory failure, diabetes mellitus, and hypertension, reported not receiving medications due to staff shortages. A review of the medication bubble pack confirmed that the medications for those days were not administered, despite being signed off in the Medication Administration Record (MAR). This discrepancy indicated inaccurate documentation and a failure to administer medications as ordered. The facility's policies on medication administration and documentation were not followed in both cases. Medications were not administered within the required time frame, and documentation in the MAR was inaccurate. The Director of Nursing confirmed these deficiencies, acknowledging that the medications were not given as scheduled and that the documentation did not reflect the actual administration of medications.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to implement a comprehensive care plan for administering medications to two residents, leading to deficiencies in medication administration. Resident 3, who was admitted with conditions including hypertension, diabetes mellitus, and respiratory failure, had a care plan that included specific medication orders. However, during a medication pass observation, it was noted that medications were administered late due to the resident's physical therapy schedule, and the late administration was not documented or communicated to the physician. This resulted in an elevated blood pressure reading that was not addressed in a timely manner, as per the facility's policy. Resident 4, who was admitted with diagnoses including respiratory failure, diabetes mellitus, and hypertension, reported not receiving morning medications for three consecutive days due to staffing shortages. A review of the medication bubble pack confirmed that medications for specific dates were not administered, despite being signed off in the Medication Administration Record (MAR). This discrepancy indicated inaccurate documentation and a failure to adhere to the prescribed medication schedule. Interviews with facility staff, including nurses and the Director of Nursing, confirmed these lapses in medication administration and documentation. The facility's policies on medication administration and comprehensive care plans were not followed, leading to potential negative impacts on the residents' health and safety. The lack of proper documentation and communication with medical doctors further exacerbated the situation, highlighting deficiencies in the facility's medication management practices.
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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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