Pacific Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 1323 17th Street, Santa Monica, California 90404
- CMS Provider Number
- 555054
- Inspections on file
- 33
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Pacific Post Acute during CMS and state inspections, most recent first.
Dignity Violations During Mealtime Assistance: Staff placed white bath towels on residents’ chests during lunch without first obtaining consent, and the DON and AD stated this could make residents feel embarrassed, uncomfortable, or childlike. Residents needing meal assistance were also referred to as "feeders" and seated at a designated table for feeders. The affected residents had significant conditions including dysphagia, CVA-related weakness, dementia, aphasia, malnutrition, blindness, and severely impaired cognition.
Past use-by foods were found stored in the kitchen refrigerator, including bagels, Swiss cheese, lettuce, and bell peppers. The DS stated these items should not be kept in the refrigerator because they can cause food borne illness if served, and the Interim DON stated serving them could lead to nausea, vomiting, diarrhea, and unnecessary hospitalization. The facility policy required safe refrigerated storage and adherence to use-by dates.
Failure to Document Acute Change of Condition: A resident with multiple chronic conditions, including dementia, malnutrition, DM2, cirrhosis with ascites, HTN, and depression, had an acute decline with refusal to eat or drink and vomiting coffee-ground emesis with blood. 911 was called and the resident was transferred to a higher level of care, but the facility did not document a COC in the EHR to reflect the sequence of events leading to the transfer.
A resident with schizoaffective disorder and dementia was ordered Seroquel 25 mg BID for agitation, but the LVN and DON stated that agitation was not the accurate indication and that the actual reason was auditory hallucinations. The facility’s policy required documented clinical rationale for medication use, and the resident’s drug regimen was not managed in accordance with that requirement.
Failure to Provide Written Bed-Hold Notice: The facility did not ensure that two residents or their representatives received timely written notice of the bed-hold policy before hospital transfer. One resident was cognitively intact with DM, hemiplegia, and ESRD, and the other was cognitively impaired with dementia and CKD; both bed-hold notices reflected telephone notification to family instead of written notice, despite the DON stating the notice should be provided in writing.
Failure to Complete Annual CNA Performance Evaluation: The facility failed to ensure that one CNA received the required annual performance review per policy. The DSD stated the CNA’s annual evaluation was overdue, and the DON stated evaluations are used to review staff performance, identify strengths and weaknesses, and determine if additional training is needed. The facility policy required formal written evaluations annually after the initial 90-day review.
A resident with DM, hemiplegia, and ESRD had orders for two fast-acting insulins, insulin aspart and insulin lispro, both given before meals. The Consultant Pharmacist identified the duplicate therapy in the MRR and recommended discontinuing one order, but staff had not notified the physician of the recommendation. An LVN and the DON acknowledged the resident had been receiving both insulins together and that the pharmacy recommendation had not been relayed to the MD.
An unlabeled zip lock bag containing multiple white pills was found in a drawer inside Medication Cart 1. RN 2 could not identify the pills, and the DON stated that unlabeled medications in the cart could be accidentally administered to a resident. The facility policy required stock medication labels to include the medication name, strength, quantity, lot and control number, and expiration date when applicable.
Insufficient Bedroom Square Footage: The facility failed to provide at least 80 sq. ft. per resident in multiple-occupancy rooms, including several rooms with two beds that measured below the required minimum. Survey observations, staff interviews, and record review showed the room sizes were measured by the Maintenance Supervisor, and the DON acknowledged the 80 sq. ft. requirement while noting the facility had requested a room waiver.
A resident with multiple complex medical conditions was discharged to an unsafe and unsanitary home environment without adequate support or proper discharge planning. The facility did not follow its discharge policy, failed to involve the IDT or the resident's POA in planning, and did not provide timely notice to the Ombudsman. As a result, the resident was left alone, sustained injuries, and required hospitalization.
The facility failed to properly dispose of medications in Medication room [ROOM NUMBER], as observed by surveyors. The pharmaceutical waste bin was found open, containing intact loose medication tablets, capsules, and other medications in their original packaging. LVN and RN confirmed that the medications were not disintegrated as per facility policy, allowing for potential misuse and diversion. The DON and Administrator acknowledged the improper disposal, which did not adhere to the facility's procedures.
The facility failed to follow its infection control policy by not labeling personal hygiene items in a shared bathroom used by four residents. Unlabeled toothbrushes, emesis basins, body soap, and toothpaste were found, posing a risk of infection spread. The residents had various medical conditions and required assistance with personal hygiene. The facility's policy emphasized standard precautions, which were not followed.
A resident in an LTC facility was left in soiled incontinence briefs and not repositioned in a timely manner, leading to feelings of discomfort and neglect. Despite having sufficient staff, CNAs prioritized meal tray distribution over immediate care needs, and the resident's requests were perceived as demanding. The facility's policies on maintaining resident dignity were not upheld.
A resident in an LTC facility experienced neglect when CNAs failed to provide timely incontinence care and repositioning, leaving her to eat with a soiled brief. Despite the facility not being short-staffed, CNAs prioritized meal tray distribution over the resident's immediate needs, leading to feelings of frustration and helplessness. The facility's policies on infection control and call light response were not properly followed, resulting in neglect of the resident's care needs.
A resident experienced neglect and frustration due to two CNAs' lack of competency in providing timely and respectful care. The resident was left waiting for incontinence care while CNAs prioritized other tasks, leading to feelings of discomfort and neglect. Misunderstandings about infection control rules and failure to seek assistance contributed to the deficiency.
The facility failed to ensure call lights were within reach for two residents, potentially delaying care. One resident with cerebrovascular accident and hemiplegia was observed with the call light out of reach, despite care plans indicating its necessity. Another resident with Parkinson's disease and muscle weakness was unable to reach the call light, which was wrapped around a siderail. Staff confirmed the importance of accessible call lights for safety and timely assistance.
The facility failed to ensure proper food labeling and storage in the kitchen, as observed by surveyors. Bags of peas and carrots in the walk-in freezer were not dated or labeled, and cheese and waffles in the overflow freezer had incorrect labeling. The Dietary Manager acknowledged these issues, which could affect 42 medically compromised residents receiving food from the kitchen.
The facility did not meet the required 80 square feet per resident in three rooms, with Rooms #9, 16, and 28 providing less space than required. Despite this, residents and staff reported adequate space for mobility and care, and a room waiver was submitted. The DON confirmed measures were taken to ensure the variance did not affect resident care.
A resident was not readmitted to the facility after hospitalization despite available beds, due to a lack of follow-up by the Admission/Business Development staff and the Director of Nursing. The resident, who required maximal assistance and had moderately impaired cognitive skills, remained in the hospital longer than necessary, contrary to the facility's Bed Hold Notice Upon Transfer policy.
A resident with a history of fracture, dysphagia, and atrial fibrillation was diagnosed with a UTI after exhibiting confusion and behavioral changes. Despite the diagnosis and antibiotic treatment, the facility failed to develop a comprehensive care plan to address the resident's UTI, as required by their policy. The Director of Nursing confirmed the absence of a care plan, highlighting a deficiency in meeting the resident's needs.
A resident was transferred from a skilled nursing facility without timely notification to the resident, their representative, or the Ombudsman. The resident, who was cognitively intact and required assistance with daily activities, was discharged to another facility with a hospice evaluation. The facility's Discharge Planner claimed the resident agreed to the transfer, but there was no documented evidence of such discussions. The Ombudsman was notified only on the day of discharge, contrary to the facility's policies.
The facility failed to provide advance written notice of room changes for three residents, violating their rights. A resident with intact cognitive skills experienced multiple incompatible roommate changes without notification, affecting her well-being. Two other residents with cognitive impairments and behavioral issues were also involved in room changes without proper notice. The facility did not adhere to its policy requiring advance notice and documentation of room changes.
A resident's grievances about disruptive roommates were not documented or addressed by the facility, despite being known to staff and management. The resident, who required moderate assistance for daily activities, experienced sleep disturbances due to roommates' behaviors, but no grievance form was completed, violating the facility's policy.
A resident with COPD and major depressive disorder experienced issues with incompatible roommates, affecting her sleep and well-being. Despite reporting these issues, the facility failed to document or address her concerns, violating policies requiring social services to coordinate necessary referrals and services.
A resident's emergency contact reported that staff did not answer phone calls and were rude during a late-night visit. Despite multiple concerns being raised about the resident's care, the Social Service Director did not initiate a grievance report, violating the facility's policy on addressing grievances.
Dignity Violations During Mealtime Assistance
Penalty
Summary
The facility failed to ensure residents were treated in a manner that enhanced dignity and respect during meals when staff placed white bath towels from the neck to the waist on residents without first obtaining consent. This occurred during lunch in the dining area, where 7 of 9 observed residents were covered with towels to protect their clothing. The facility’s RN stated the towels were used for residents who needed assistance with meals to prevent food from spilling on their clothes. The DON stated that placing a towel in front of residents during mealtimes without the resident’s consent can make residents feel embarrassed and that staff must ask for consent before doing so. The AD also stated that placing a towel on a resident without obtaining consent during mealtimes can make the resident uncomfortable and feel childlike. The residents involved had significant medical and functional needs. Resident 23 was admitted with dysphagia due to cerebral infarction, muscle weakness, and dementia, and the MDS showed severely impaired cognition with moderate assistance needed during meals. Resident 20 had legal blindness, muscle weakness, lack of coordination, and severely impaired cognition, with set up and clean up assistance needed during meals. Resident 36 had dysphagia due to cerebral infarction, hemiplegia, hemiparesis, and severely impaired cognition, with supervision and/or touching assistance needed during meals. Resident 26 had hemiplegia, hemiparesis, aphasia, dysphagia, protein-calorie malnutrition, and no capacity for medical decision making due to CVA. Additional residents observed or reviewed included Resident 39, who had dysphagia, muscle weakness, and moderately impaired cognition; Resident 14, who had aphasia, protein-calorie malnutrition, and severely impaired cognition; and Resident 43, who had dysphagia due to cerebral infarction, protein-calorie malnutrition, and severely impaired cognition. The facility policy titled Promoting/Maintaining Resident Dignity stated that care or procedures should be explained to residents before initiating the activity and that residents should be treated with respect and dignity while recognizing each resident’s individuality. The facility also referred to residents requiring meal assistance as "feeders." During a meal observation, Residents 10, 13, 20, 22, 23, 26, 29, and 36 were seated at a table designated for feeders, and the AD stated the listed room numbers were feeders because they needed assistance eating due to mobility issues, poor vision, or broken arms. The Interim AD stated that residents requiring assistance with meals were called feeders. The Interim DON stated that residents requiring assistance with meals should not be called feeders because it is a dignity issue and violates a resident’s inherent worth, self-respect, or right to be valued.
Past Use-By Foods Stored in Kitchen Refrigerator
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices in the kitchen by allowing foods with past use-by dates to remain stored in the kitchen refrigerator. During a kitchen tour on 3/31/2026 at 7:51 am, surveyors observed a zip lock plastic bag of bagels dated thawed on 3/11/2026 with a use-by date of 3/17/2026, a clear plastic bag of Swiss cheese dated 3/26/2026 with a use-by date of 3/30/2026, a clear plastic bag of lettuce with a use-by date of 3/27/2026, and a clear plastic bag of bell peppers with a use-by date of 3/27/2026, all stored in the refrigerator. During interview, the Dietary Supervisor stated that food with past due use-by dates should not be placed in the refrigerator because they can cause food borne illness if served to residents. The Interim DON stated that if food with a past use-by date were served and consumed by residents, it could cause food borne illness such as nausea, vomiting, and diarrhea, resulting in unnecessary hospitalization and potential poor outcomes for residents. The facility policy titled, Food Safety and Food Storage dated 11/19/2025 stated that food safety practices shall be followed throughout the facility's entire food handling process, including storage of food in a manner that helps prevent contamination and practices to maintain safe refrigerated storage, including use-by dates.
Failure to Document Acute Change of Condition
Penalty
Summary
Facility failed to document an acute change of condition for one resident after the resident experienced a sudden decline that required transfer to a higher level of care. The resident was admitted with diagnoses including protein calorie malnutrition, type 2 diabetes mellitus, alcoholic cirrhosis of the liver with ascites, hypertension, major depressive disorder, and dementia. The resident’s MDS indicated severely impaired cognition and significant dependence for activities of daily living, including eating, dressing, oral hygiene, personal hygiene, toileting hygiene, shower bathing, and walking up to 10 feet. The medical record showed that on the day of the event the resident was not feeling well, refused to eat or drink, and vomited coffee-ground colored material with blood. 911 was called, and emergency responders arrived while the resident was still vomiting and transferred the resident to a higher level of care. A nursing progress note documented these events, but the facility did not document a change of condition in the resident’s electronic health record to reflect the sequence of events leading to the transfer. During interviews, an LVN stated that a COC is not done for an acute incident when 911 is called, while the IDON stated that a COC should have been documented to communicate the resident’s healthcare changes to the physician, interdisciplinary team, and family.
Unnecessary Psychotropic Medication Ordered With Inaccurate Indication
Penalty
Summary
The facility failed to ensure that one of five sampled residents, Resident 20, was free of unnecessary medication in accordance with its policy on unnecessary drugs without adequate indication for use. Resident 20 was admitted with diagnoses including schizoaffective disorder, dementia affecting the right nondominant side, and atrial fibrillation. The resident’s MDS dated 3/11/2026 indicated cognitive impairment and that the resident required set up/clean up to partial/moderate assistance with ADLs. A physician’s order dated 3/20/2026 directed Seroquel 25 mg by mouth twice a day for agitation. During a concurrent interview and record review, the LVN stated that agitation was not the accurate reason for the Seroquel order and that the actual indication was auditory hallucinations. The DON also stated that the indication of agitation was not an acceptable diagnosis and that an accurate diagnosis needed to include a manifestation of a certain behavior. The facility’s policy required that each resident’s drug regimen be managed and monitored with documented clinical rationale for use, and that staff act upon pharmacist medication regimen review recommendations.
Failure to Provide Written Bed-Hold Notice
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing, in a timely manner, of the bed-hold policy prior to transfer to the hospital, as required by the facility's Bed Hold Prior to Transfer policy. Two sampled residents were affected. One resident was admitted with diagnoses including DM, right-sided hemiplegia, and ESRD, and was documented as cognitively intact on the MDS while requiring partial/moderate to substantial/maximal assistance with ADLs. The resident's bed-hold notice reflected telephone notification to the resident family rather than written notice. A second resident was admitted and later readmitted with diagnoses including cognitive communication difficulty, dementia, and chronic kidney disease, and was documented as cognitively impaired on the MDS while requiring partial/moderate to substantial/maximal assistance with ADLs. The resident's bed-hold notice also reflected telephone notification to the resident family. During interviews, the LVN stated that for emergency transfers or cognitively impaired residents, the 7-day bed hold is given to the resident representative via telephone and that he had never mailed a 7-day bed hold notice. The DON stated that the 7-day bed hold should be given as a written notice to residents and/or mailed to the resident's representative. The facility policy stated that written information about bed-hold policies is to be provided to residents and/or resident representatives prior to and upon transfer.
Failure to Complete Annual CNA Performance Evaluation
Penalty
Summary
The facility failed to ensure that one of two CNAs received an annual performance review according to its policy and procedures titled Evaluation Process. During a concurrent interview and record review on 4/3/2026, the employee file for CNA 1 showed that the CNA was hired on 8/7/2024. The Director of Staff Development stated that the facility’s performance evaluation process is completed 90 days after hire and annually thereafter, and stated that CNA 1 did not have an annual performance evaluation completed when it should have been done on 1/2/2025. During interview, the DON stated that annual performance evaluations are used to review staff performance, identify strengths and weaknesses, provide feedback, and determine whether additional training is needed. The DON also stated that evaluations are completed after 90 days for new hires and then annually. The facility’s policy stated that employee work performance is to be reviewed with a formal written evaluation annually, and that performance evaluations are used in determining promotions, demotions, transfers, terminations, and salary or wage adjustments.
Failure to Act on Pharmacist Review of Duplicate Fast-Acting Insulin Orders
Penalty
Summary
The facility failed to ensure that one sampled resident was free of unnecessary medication when it did not act on the Consultant Pharmacist’s medication regimen review recommendation regarding duplicate fast-acting insulin orders. The resident was admitted with diagnoses including DM, right-sided hemiplegia, and ESRD, and the MDS dated 3/16/2026 indicated the resident was cognitively intact and required partial/moderate to substantial/maximal assistance with ADLs. The resident’s physician orders showed insulin aspart 8 units subcutaneously before meals and at bedtime for DM2, and insulin lispro 2 units subcutaneously before meals for DM2. The Consultant Pharmacist’s medication regimen review on 3/20/2026 identified two orders for fast-acting insulin before meals, insulin aspart and insulin lispro, and recommended that one of the orders be reviewed and discontinued. During interview and record review, LVN 1 stated that lispro and aspart are both fast-acting insulins and should not be given together at once, and stated the resident had been receiving both since they were ordered on 1/29/2026. LVN 1 also stated the physician had not been notified of the pharmacy recommendation. The DON stated the facility process was for the DON or designated staff to notify the physician of pharmacist recommendations, but acknowledged the recommendation had not been relayed to the physician.
Unlabeled Pills Found in Medication Cart
Penalty
Summary
The facility failed to label a small zip lock bag containing multiple white pills found in a drawer inside Medication Cart 1. During observation in the hallway, the unlabeled bag was seen in the medication cart, and the bag did not identify the name of the pills inside. RN 2 stated she could not identify the white pills in the bag and said they could be accidentally administered to a resident and cause harm. The DON also stated that any unlabeled medications found in the medication cart could accidentally be administered to a resident. The facility policy titled "Labeling of Medication and Biologicals" stated that stock medication labels must include the medication name, strength, quantity, lot and control number, expiration date when applicable, and other required information.
Insufficient Bedroom Square Footage
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms, including Rooms 9, 11, 14, 16, 26, 27, and 28. The report states that this deficient practice involved seven of 25 resident rooms and was identified during observation, interview, and record review. The cited room measurements showed several rooms with floor areas below the required minimum for multiple-occupancy rooms, including rooms measured at 147.9 sq. ft., 147.4 sq. ft., 143.2 sq. ft., 134.35 sq. ft., and 156.4 sq. ft. with two beds in the room. During the recertification survey, staff interviews indicated there were no concerns regarding the size of the rooms, and observations from 3/31/2026 to 4/3/2026 noted residents had ample space to move freely inside the rooms. A concurrent observation and interview with the Maintenance Supervisor documented the method used to measure room size, and the DON stated the required square footage per resident is 80 sq. ft. The DON also stated the facility requested a room waiver so the square footage would be acceptable even if it did not meet the regulatory requirement.
Failure to Ensure Safe and Orderly Discharge Planning
Penalty
Summary
The facility failed to provide an effective and safe discharge for a resident with complex medical needs, resulting in the resident being discharged to an unsafe home environment without adequate support or preparation. The facility did not follow its own discharge planning policy and procedure, as the interdisciplinary team (IDT) did not ensure that the discharge destination met the resident's health and safety needs or preferences. The care plan for discharge was not properly implemented, and the discharge summary lacked input and recommendations from the IDT, with sections left blank and signed off by a staff member who did not provide the required education or assessment. The resident had significant medical conditions, including Parkinson's disease, a recent above-knee amputation, diabetes, chronic kidney disease, and major depressive disorder. The resident required moderate assistance with activities of daily living, used a wheelchair, and had a non-weight bearing order on the left lower extremity. The resident's home environment was documented as cluttered, unsanitary, and lacking caregiver support, with the only available support being a power of attorney (POA) who lived an hour away and was not regularly present. Despite these factors, the facility discharged the resident home with only a home health agency referral, without confirming the adequacy of support or the safety of the environment. The discharge notice was not provided to the resident's representative or Ombudsman in a timely or understandable manner, and the POA was not included in discharge planning meetings. The facility staff did not coordinate with the IDT or verify the resident's home situation, and Adult Protective Services was not contacted despite the apparent risks. As a result, the resident was left alone at home for several days, was found on the floor with injuries, and required hospitalization. The facility's failure to follow its discharge planning process and ensure a safe transition led directly to the resident's harm.
Improper Disposal of Medications in Medication Room
Penalty
Summary
The facility failed to properly dispose of medications in a manner that prevents retrieval, as observed in Medication room [ROOM NUMBER]. During an inspection, it was found that the pharmaceutical waste bin was open and contained a mixture of intact loose medication tablets and capsules, medications in manufacturer bottles, creams/ointments, and unopened and unused suppositories and patches in their original packaging. Licensed Vocational Nurse (LVN) 3 and Registered Nurse (RN) 1 confirmed that the medications were disposed of in their original form without any liquid poured over them to disintegrate the medications, contrary to the facility's policy and procedures. The Director of Nursing (DON) and the Administrator acknowledged that the medications in the pharmaceutical waste bin were not disposed of properly, allowing for easy access, retrieval, and potential re-use. The facility's policies and procedures, as reviewed, indicated that outdated, contaminated, or deteriorated medications should be immediately removed from stock and disposed of according to procedures for medication disposal. However, the facility failed to adhere to these procedures, increasing the potential for accidental misuse and diversion of medication, and exposure to harmful substances.
Infection Control Deficiency Due to Unlabeled Personal Hygiene Items
Penalty
Summary
The facility failed to adhere to its infection control policy and procedure by not labeling personal hygiene items in a shared bathroom used by four residents. During an observation, it was noted that two toothbrushes, two emesis basins, two bottles of body soap, and one toothpaste were found unlabeled in the shared bathroom. This oversight was confirmed by a Certified Nurse Assistant/Restorative Nurse Assistant, who acknowledged that such items should not be left unlabeled as it could lead to the spread of infection among residents. The residents involved had various medical conditions, including major depression disorders, protein-calorie malnutrition, gastro-esophageal reflux disease, immunodeficiency, type 2 diabetes mellitus, and dementia, among others. The Minimum Data Set assessments indicated that these residents required varying levels of assistance with personal hygiene and had intact or moderately impaired cognitive skills for daily decision-making. The facility's policy, revised in December 2024, emphasized the importance of following standard precautions for infection prevention and control, which was not adhered to in this instance.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident, identified as Resident 390, by not providing timely incontinence care and repositioning assistance. On multiple occasions, Resident 390 was left in soiled incontinence briefs for extended periods, including a specific incident where the resident had to wait 40 minutes for care. This delay occurred because CNA 3 prioritized passing meal trays over attending to the resident's immediate needs, despite the facility not being short-staffed. The resident expressed feelings of discomfort, frustration, and neglect due to these delays and the manner in which the staff communicated with her. Additionally, Resident 390's requests for repositioning were not promptly addressed. CNA 4, who was responsible for the resident's care at another time, delayed repositioning the resident after returning from a break, assuming that the resident could wait. The resident's frequent use of the call light and requests for assistance were perceived as demanding by the staff, leading to further delays in care. The staff's failure to respond promptly to the resident's needs and their elevated tone of voice contributed to the resident feeling disrespected and treated like a child. The facility's policies and procedures emphasize the importance of maintaining resident dignity and responding to requests for assistance in a timely manner. However, the actions and inactions of the staff, including not asking for help when needed and not prioritizing the resident's immediate care needs, resulted in a failure to uphold these standards. Interviews with the Director of Nursing and the Administrator confirmed that the facility had sufficient staff to address the resident's needs and that the infection control concerns cited by CNA 3 were not valid reasons for delaying care.
Neglect in Resident Care Due to Delayed Incontinence Management
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by the actions of CNAs who did not provide timely incontinence care and repositioning. The resident, who was unable to walk and care for herself, reported feeling upset, frustrated, helpless, and neglected due to the delay in care. On one occasion, the resident had to wait up to 40 minutes to be cleaned after a bowel movement, during which time she was left to eat with a soiled incontinence brief. The CNAs involved did not prioritize the resident's request for care, citing other duties such as passing meal trays. Interviews with staff revealed that CNA 3 did not clean the resident immediately due to an incorrect belief that infection control rules prohibited incontinence care during meal tray distribution. The Director of Staff Development and the Director of Nursing confirmed that there was no such rule, and proper handwashing would suffice to address infection control concerns. Additionally, the facility was not short-staffed, and CNA 3 could have asked for assistance to ensure the resident's needs were met promptly. The resident's care plan indicated a need for regular checks and assistance with toileting, which was not adhered to. The facility's policy on call light response was also not followed, as the resident's requests were not addressed in a timely manner. The Director of Nursing and the Administrator acknowledged that the failure to provide immediate care constituted neglect, as it did not meet the resident's needs for comfort and safety, potentially leading to physical and emotional distress.
Inadequate CNA Competency Leads to Resident Neglect
Penalty
Summary
The facility failed to ensure that two Certified Nurse Assistants (CNAs) had the necessary competencies to provide care in a respectful and timely manner, which affected Resident 390. During an observation and interview, Resident 390 expressed feelings of sadness and frustration due to being told by CNAs in a harsh tone that she would need to wait for incontinence care. On one occasion, Resident 390 requested a change of her incontinence brief after a bowel movement, but CNA 3 prioritized passing meal trays over providing immediate care, leading to Resident 390 feeling uncomfortable and neglected. CNA 4 described Resident 390 as demanding and stated that call lights were answered in the order they were activated, with no complaints from other residents. CNA 4 did not seek assistance from other staff, assuming they were busy, and emphasized that Resident 390's requests were not emergencies. CNA 3 believed there was an infection control rule preventing them from providing incontinence care while passing meal trays, which led to confusion about prioritizing tasks. CNA 3 admitted to needing further training on handling such situations. The Director of Staff Development (DSD) clarified that there was no infection control rule prohibiting incontinence care during mealtime and emphasized the importance of proper handwashing. The DSD and Director of Nursing (DON) both highlighted the need for CNAs to be competent in their duties, respectful, and protective of residents' dignity. The facility's policy and job description for CNAs outlined the expectation for staff to treat residents with dignity and respect, and to perform their duties in accordance with established policies and procedures.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, which had the potential to delay their care. Resident 21, who was admitted with diagnoses including cerebrovascular accident, hemiplegia with left-sided weakness, and muscle weakness, was observed with the call light out of reach on multiple occasions. The resident's care plan indicated the need for the call light to be within reach due to communication issues and fall risk. Despite this, observations showed the call light was either hanging from the bed or placed under a pillow, making it inaccessible. Interviews with staff confirmed the importance of having the call light within reach to prevent delays in care and potential injuries. Similarly, Resident 390, who had diagnoses including Parkinson's disease, diabetes mellitus, and muscle weakness, was observed unable to reach the call light while sitting in a wheelchair. The call light was wrapped around the bed's siderail, approximately three feet away from the resident. The resident's care plan also emphasized the need for the call light to be within reach due to fall risk. Staff interviews reiterated the necessity of ensuring call lights are accessible to residents to facilitate communication and maintain safety. The facility's policy on call light accessibility and timely response was not adhered to in these instances.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Specifically, the surveyors found that bags of peas and carrots in the walk-in freezer were not dated or labeled. The Dietary Manager (DM) acknowledged that the cook had just opened these bags but forgot to label them with the date they were opened and the use-by date. The DM emphasized the importance of labeling food to prevent the use of expired items and to avoid serving food that could cause illness to residents. Additionally, the surveyors observed that cheese and waffles in the overflow freezer were not correctly labeled and dated. The cheese had a use-by date that should have been updated when it was moved to the freezer, and the waffles had an incorrect open date and use-by date. The DM admitted that the dates on these items were labeled incorrectly. The facility's policy and procedure on food safety and storage, which requires proper labeling, dating, and monitoring of refrigerated food, was not followed, potentially affecting 42 medically compromised residents who received food from the kitchen.
Facility Fails to Meet Space Requirements in Three Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in three rooms, specifically Rooms #9, 16, and 28. Observations and interviews revealed that these rooms did not meet the federal regulation for space per resident, with Room #9 providing 74.48 square feet per resident, Room #16 providing 71.91 square feet per resident, and Room #28 providing 78.79 square feet per resident. Despite this, residents and staff reported that there was adequate space for mobility and care, and a room waiver request was submitted indicating that the rooms were in accordance with the residents' special needs and provided enough space for dignity and privacy. The Director of Nursing confirmed the existence of a room waiver and stated that measures were taken to ensure the room variance did not adversely affect resident care.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident following hospitalization, despite having available beds, in accordance with its Bed Hold Notice Upon Transfer policy. The resident, who had been admitted to the facility with diagnoses including metabolic encephalopathy, chronic embolism, and thrombosis, required maximal assistance for activities of daily living and had moderately impaired cognitive skills. After being transferred to a general acute care hospital for further evaluation, the resident was ready for discharge back to the facility. However, the facility did not facilitate the resident's timely readmission. The Admission/Business Development (AD/BD) staff received the referral for the resident's readmission but was out of town and failed to follow up upon returning. The Director of Nursing (DON) was unaware of the resident's continued hospitalization and did not follow up with the hospital when beds became available. The facility's policy requires that residents be allowed to return unless specific conditions are met, none of which applied in this case. The failure to readmit the resident resulted in the resident remaining in the hospital longer than necessary.
Failure to Implement Comprehensive Care Plan for UTI
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who experienced a change in condition due to a urinary tract infection (UTI). The resident, who was admitted with diagnoses including a fracture of the left ilium, dysphagia, and paroxysmal atrial fibrillation, was found to be confused and acting out, which led to a urinalysis being ordered. The resident was subsequently diagnosed with a UTI and prescribed antibiotics. Despite this change in condition, no care plan was developed to address the UTI diagnosis and the associated treatment. The facility's policy requires the development of a comprehensive, person-centered care plan for each resident, which includes measurable objectives and timeframes to meet the resident's needs. However, a review of the resident's electronic and paper health records confirmed the absence of such a care plan. The Director of Nursing acknowledged that no care plan was created for the resident's UTI diagnosis, which is a deficiency in meeting the facility's policy and potentially impacts the resident's health and safety.
Failure to Provide Timely Notification of Transfer and Discharge
Penalty
Summary
The facility failed to provide timely notification of a proposed transfer and discharge to a resident, as well as to the resident's representative and the State Long Term Care Ombudsman. This deficiency was identified for one resident who was transferred from Skilled Nursing Facility 1 to another facility. The resident, who had been at the facility for over two years and considered it home, was not given adequate notice or documentation of the transfer, leading to feelings of anxiety and distress. The resident, who was cognitively intact and required assistance with activities of daily living, was discharged to another skilled nursing facility with a hospice evaluation. The discharge was reportedly initiated by the facility's Discharge Planner, who claimed that the resident had agreed to the transfer. However, there was no documented evidence of any discussions or requests from the resident for a discharge. The Social Services Director and the Director of Nursing were also unaware of any prior desire from the resident to be discharged, and the Ombudsman was only notified on the day of the discharge. The facility's policy and procedures for discharge planning emphasize the importance of documenting the resident's discharge goals and needs, as well as providing education to the resident and family prior to discharge. In this case, the facility did not adhere to its own policies, as there was no documentation of the resident's desire to be discharged, and the Ombudsman was not informed in a timely manner. This lack of communication and documentation resulted in the resident being transferred without the necessary protections and support.
Failure to Provide Advance Notice for Room Changes
Penalty
Summary
The facility failed to uphold residents' rights by not providing advance written notice of room or roommate changes for three residents, as required by their policy. Resident 1, who had intact cognitive skills and required moderate assistance for daily activities, experienced multiple roommate changes without proper notification. The resident expressed dissatisfaction with previous roommates due to their behavioral issues, which affected her sleep and well-being. Resident 2, with moderately impaired cognitive skills and requiring maximal assistance, was involved in the room change process without receiving the necessary advance notice. Similarly, Resident 3, who had moderate to total dependence on staff for daily activities and exhibited behavioral issues such as aggressiveness and sundowning, was also part of the room change without proper notification. Interviews with staff revealed that these residents had behavioral issues that contributed to the incompatibility with Resident 1. The Director of Nursing acknowledged the lack of documentation and adherence to the facility's policy regarding room changes. The facility's policy stated that residents and their representatives should receive advance written notice of room changes, including the reasons for the change, in a language and manner they understand. However, this procedure was not followed, leading to the deficiency in promoting residents' rights.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to promptly address grievances for a resident, violating their right to have grievances resolved without discrimination or reprisal. The resident, who was cognitively intact and required moderate assistance for activities of daily living, had repeatedly expressed concerns about incompatible roommates who exhibited disruptive behaviors, such as yelling and screaming at night. These disturbances affected the resident's sleep and well-being, and the resident had informed the staff and management about these issues. Despite the resident's vocal complaints, no grievance form was completed to document these concerns. Interviews with staff, including two Licensed Vocational Nurses and the Director of Nursing, confirmed that the resident's grievances were known but not formally recorded or addressed. The facility's grievance policy mandates that grievances be documented and resolved, but in this case, the grievance forms were not updated, leading to a failure in addressing the resident's concerns adequately.
Failure to Provide Necessary Social Services Referrals
Penalty
Summary
The facility failed to provide necessary social services referrals for a resident, leading to a deficiency in care. The resident, who was admitted with chronic obstructive pulmonary disease, major depressive disorder, and muscle weakness, had intact cognitive skills and required moderate assistance for activities of daily living. Despite having a care plan goal to improve mood and reduce symptoms of depression and anxiety, the resident experienced issues with incompatible roommates who exhibited disruptive behavior, affecting her sleep and well-being. The resident reported these issues to the staff, but no documented actions were taken to address her concerns. During an interview, the Director of Nursing acknowledged that the facility's grievance forms and room change notifications were not updated, indicating a failure to follow established policies. The facility's policy required social services to coordinate resident referrals and collaborate with nursing staff to arrange necessary services. However, the lack of documentation and follow-up on the resident's grievances and room change requests demonstrated a failure to meet the resident's medically related emotional and social needs, as outlined in the facility's job description for the Social Service Designee.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure prompt attempts were made to resolve grievances for a resident, violating the resident's responsible party's right to have grievances addressed and resolved. The resident, who was admitted with diagnoses including cerebral infarction, dysphagia, and major depressive disorder, had severely impaired cognition and required maximal assistance for activities of daily living. On one occasion, the resident's emergency contact visited the facility at 1:00 a.m. and found that staff did not answer phone calls and were rude and unprofessional. The emergency contact reported the incident to the management, but no grievance report was initiated by the Social Service Director, despite multiple concerns being raised previously about the resident's care. The facility's policy and procedures on resident and family grievances state that grievances should be addressed without discrimination or reprisal, and the Grievance Official should take steps to resolve the grievance and record the actions taken. However, the Social Service Director admitted to not following the grievance procedure, even though she was aware of the incidents and concerns raised by the resident's emergency contact. This failure to follow the grievance policy resulted in the resident's grievances not being promptly addressed or resolved, as required by the facility's own policies.
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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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