Palazzo Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 5400 Fountain Ave, Los Angeles, California 90029
- CMS Provider Number
- 056456
- Inspections on file
- 36
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Palazzo Post Acute during CMS and state inspections, most recent first.
A CNA worked an overnight 11 p.m. to 7 a.m. shift without an active CNA certification, in violation of federal nurse aide registry requirements and the facility’s job description requiring a valid CNA license. The DON had a personnel file printout indicating the CNA’s status was active and employable, but a concurrent CDPH registry search showed no matching data. Review of assignment and attendance sheets confirmed the CNA worked the shift after being called in by a Charge Nurse who did not realize the CNA had been removed from the schedule for lapsed certification. The DSD reported that CNAs with expired certifications are taken off the schedule and payroll and that this CNA had been informed of her limitations, yet she still worked the shift without valid certification.
A resident with a history of severe psychiatric disorders exhibited aggressive behavior requiring 1:1 supervision, but the facility did not update the care plan to reflect this intervention after significant behavioral changes and hospital readmission. Staff interviews and record reviews confirmed that the care plan was not revised as required by facility policy, leaving the resident's current needs and interventions undocumented.
A resident with multiple health conditions, including blindness and psychiatric diagnoses, became agitated after being denied a request to smoke. A CNA attempted to prevent the resident from getting up, but did not notify the RN of the agitation. Another resident, believing the CNA was at risk, struck the agitated resident on the jaw, causing pain and requiring an x-ray. Facility policies required staff to prevent and report abuse, but these were not followed, resulting in physical harm.
Two residents, both with significant medical and behavioral histories, were involved in a physical altercation after one became agitated over smoking restrictions and the other intervened, believing staff were at risk. Staff failed to notify the RN of escalating agitation and did not provide adequate supervision, resulting in one resident being struck and requiring medical evaluation.
A resident with impaired mobility and a high risk for falls was not properly positioned in a wheelchair after a toilet transfer, resulting in a fall. Despite a care plan requiring assistance and safety interventions, staff failed to ensure correct seating before moving the wheelchair, leading to the incident. The resident did not sustain injuries.
The facility failed to properly manage emergency drug supplies, resulting in the absence of a narcotic E-kit for about 24 hours, did not replace E-kits within the required timeframe, and left several drug disposition forms incomplete. Additionally, staff did not adequately follow up or document actions regarding a resident's pending Norco opioid order, leading to delays in medication availability.
Surveyors found that kitchen staff did not keep the ice scooper holder clean, stored personal perishable food in the facility refrigerator, and left personal items in non-designated kitchen areas. The Dietary Food Nutrition Supervisor confirmed these actions violated facility policies for food safety and sanitation.
Surveyors observed that staff failed to follow infection prevention protocols, including not wearing required gowns during direct care for a resident on enhanced barrier precautions and not disinfecting IV injection ports during medication administration. Additionally, the facility's water management plan lacked critical details, such as building and water system descriptions, control measures, and verification steps, as confirmed by facility leadership.
A resident with severe cognitive impairment and multiple mental health diagnoses was allowed to sign medical consent forms and an Advance Health Care Directive without the involvement of a legal representative, despite documentation and staff acknowledgment of the resident's incapacity. Staff obtained verbal consent and witnessed signatures instead of following procedures for residents lacking decision-making capacity.
A resident with a history of falls and neurological conditions experienced a fall, but the care plan was not updated to reflect this incident or to add new interventions. Despite facility policy and staff acknowledgment that care plans should be revised after such events, the last update had occurred months earlier, resulting in a deficiency related to care plan management.
A resident with severe cognitive impairment, dysphagia, and a g-tube was observed with poor oral hygiene, including a tan substance on teeth, dry lips, and a reddened, swollen tongue. Staff interviews revealed oral care was not provided as frequently as care plans required, and the resident's mouth had been in poor condition for some time. The DON confirmed that the observed oral condition was unacceptable and not in line with facility policy.
Staff failed to lock both the bed and the Hoyer lift before placing a sling under a resident with significant mobility impairments and a history of falls. This action was inconsistent with the resident's care plan and facility policy, as confirmed by staff interviews and direct observation.
A resident with multiple medical conditions and frequent incontinence did not receive a quarterly bowel and bladder assessment as required by their care plan. Documentation and staff interviews confirmed that the last assessment was completed several months prior, and facility policy requiring regular continence assessments was not followed.
A resident dependent on g-tube feeding due to dysphagia and malnutrition was found to have an unlabeled flush bag attached to their feeding pump, despite the care plan requiring labeling with date, time, and nurse's initials. Both nursing staff and the DON acknowledged the omission and the associated risk of infection.
A resident with a history of fibromyalgia and skin sensation disturbances experienced facial itching due to a possible allergic reaction. Although a physician ordered Benadryl 25 mg to be given as needed, review of the MAR showed the medication was not documented as administered, and the resident reported not receiving it. Interviews with nursing staff and review of facility policy confirmed the lack of required documentation for medication administration.
The facility did not post the actual hours worked by staff, as required by federal regulations. On the observed day, only projected hours were displayed, and the previous day's actual hours were missing. Interviews with the DSD and DON revealed a misunderstanding of the posting requirements, which were clarified upon reviewing the facility's policy.
A resident with multiple myeloma missed two doses of Pomalyst due to the facility's failure to implement a consistent medication reconciliation system. The resident, who also had type 2 diabetes and end-stage renal disease, was aware of the prescription but reported not receiving the medication as ordered. The DON confirmed the missed doses, and an LVN admitted to not administering the medication due to its unavailability in the medication cart. The facility's policy required medications to be administered safely and as prescribed, which was not followed.
The facility failed to uphold resident dignity and respect, as evidenced by two residents reporting incidents of staff yelling. One resident, with conditions including hypertension and cellulitis, was yelled at by a CNA after assisting another resident. Another resident, with osteoarthritis and reduced mobility, confirmed hearing an argument involving staff. Both residents had intact cognition and required assistance for daily activities, highlighting a breach in the facility's policy on resident rights.
A resident with an amputation site, acute respiratory failure, and an arterial ulcer did not receive necessary care and services. The facility failed to assess and document the ulcer upon admission, did not develop a comprehensive care plan, and did not follow the physician's treatment order. Additionally, the resident's respiratory status was not adequately monitored, leading to their transfer to a hospital where they were diagnosed with further complications and subsequently passed away.
A resident at risk for malnutrition did not receive 17 doses of Megestrol Acetate Suspension due to the medication not being in stock, leading to significant weight loss. The facility failed to maintain accurate medication administration records, marking the medication as administered when it was not available. Interviews with staff revealed a lack of adherence to documentation practices, contributing to the deficiency.
The facility failed to label and date food stored in the kitchen, including bread and various frozen vegetables, as observed during a kitchen tour. Both the Dietary staff and the DON acknowledged that all food should be labeled and dated to prevent food-borne illnesses, in accordance with the facility's policy.
A resident with Type II diabetes and other conditions experienced a significant change in health status with elevated blood sugar levels. The LTC facility failed to develop an individualized care plan to address hyperglycemia, as required by policy, leading to inadequate care and monitoring. Interviews with staff confirmed the oversight in care planning.
A resident with a right heel deep tissue injury did not receive necessary care and services as per their care plan, which included monitoring and documenting changes in the wound's condition. For 16 days, there was no documentation of the wound's status, despite facility policies requiring detailed recording of treatment and assessment data. This oversight was confirmed by staff interviews and posed a risk of infection or worsening of the wound.
A resident with a history of falls did not receive the necessary fall prevention interventions as outlined in their care plan. The facility failed to implement the required measures, such as a yellow star on the wall, a fall risk wristband, and non-skid socks. Additionally, the care plan was not updated following a fall that resulted in a skin abrasion. The facility's policies on fall risk management and care plan updates were not followed.
A resident with acute respiratory failure was not provided with proper respiratory care as their nasal cannula tubing was neither labeled nor stored in a plastic bag, contrary to facility policy. Staff interviews confirmed the tubing should have been labeled and stored correctly to prevent infection, as per the care plan and facility guidelines.
A resident continued to receive Effexor for depression without documented justification beyond 30 days. Despite the absence of verbalized sadness, the Consultant Pharmacist's Medication Regimen Review lacked recommendations or rationale for the medication's continued use. The facility's policy required monthly reviews and reporting of medication irregularities, but no Gradual Dose Reduction was documented.
A resident experienced significant weight loss due to the unavailability of Megestrol Acetate Oral Suspension for 17 days. The medication, intended to stimulate appetite, was inaccurately documented as administered by multiple nurses. The resident's weight dropped from 182 to 156 pounds, and the facility's policies on medication administration and documentation were not adhered to.
A facility failed to store Dorzolamide-Timolol Ophthalmic Solution correctly, as it was found in a refrigerator instead of being stored at room temperature as per manufacturer's guidelines. This improper storage was acknowledged by an LVN and confirmed by the DON, who noted that it could render the medication ineffective for treating a resident's eye condition.
A resident with multiple medical conditions, including dependence on renal dialysis, was inappropriately administered MiraLAX despite experiencing frequent loose stools. The facility failed to notify the physician of the resident's condition change, continuing the laxative treatment without adjustment. Staff interviews revealed a lack of awareness and communication regarding the resident's diarrhea, and the DON acknowledged the oversight. The facility's policies on notifying changes in condition were not followed, posing a risk of dehydration and other complications.
A facility failed to review transfer records for a resident admitted with multiple medical conditions, resulting in missed critical appointments for vascular diagnostics, chemotherapy, and specialist consultations. The oversight occurred because the admitting nurse only reviewed medication pages, leading to a delay in the resident's treatment.
A facility failed to safeguard a resident's personal funds by improperly storing $800 in a narcotic box instead of transferring it to the business office the next business day, as required by policy. The delay and improper storage posed a risk of theft or misuse.
CNA Allowed to Work Overnight Shift Without Active Certification
Penalty
Summary
Surveyors identified that one CNA worked an overnight 11 p.m. to 7 a.m. shift without an active CNA certification, contrary to federal nurse aide registry requirements and the facility’s own job description, which requires a valid CNA certification. During interview and record review with the DON, the CNA’s Licensing & Certification Verification Detail Page in the personnel file showed an active, employable status with a future expiration date, which the DON had relied upon. However, when the DON searched the California Department of Public Health (CDPH) website during the same review, no data was found for the CNA, confirming that the CNA did not have an active certification on the registry at the time she worked the shift. Further review of the nursing assignment and attendance sign‑in sheets for the overnight shift confirmed that the CNA had signed in and worked that shift. The DON stated that the situation occurred because the evening shift Charge Nurse, attempting to cover a CNA call‑off, contacted this CNA, who was known for helping cover shifts, and did not recognize that she had been removed from the schedule due to lapsed certification. In a separate telephone interview, the DSD explained that CNAs with lapsed certifications are removed from the monthly schedule and payroll until their certification is valid, and that this CNA had been informed of what she could and could not do with an expired certification. The DSD also noted that the CNA should have known her status when the system would not allow her to clock in, yet she knowingly worked the shift without a valid CNA certification.
Failure to Update Care Plan for Aggressive Behavior and 1:1 Supervision
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's aggressive behavior and need for 1:1 supervision following significant changes in the resident's condition. On one occasion, the resident exhibited aggressive behavior, including spitting at a nurse, which resulted in a physician's order for 1:1 supervision. Despite this, a care plan reflecting the new intervention was not created or updated on the same day. Documentation and interviews confirmed that the care plan did not include the required interventions for aggressive behavior or 1:1 supervision at that time. Subsequently, the resident was transferred to a general acute care hospital for further evaluation due to increased agitation and aggression. Upon readmission to the facility, the care plan still lacked updates to address the resident's aggressive behavior and the need for 1:1 supervision. Multiple staff interviews, including those with LVNs, an RN, and the DON, confirmed that the care plan was not revised to reflect the resident's current needs and interventions after these significant events. Record reviews and staff statements indicated that the facility's policies and job descriptions required care plans to be updated with any significant change in a resident's condition or upon readmission from a hospital stay. However, these procedures were not followed, resulting in the absence of an accurate and current care plan for the resident during periods of behavioral escalation and after hospital readmission.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident took place when a resident, who was blind and had a history of schizophrenia, bipolar disorder, and nicotine dependence, became agitated after being told by a CNA that it was not time to smoke. The CNA attempted to prevent the resident from getting up due to fall risk, but did not notify the RN of the resident's agitation. Another resident, who had type 2 diabetes, blindness in one eye, and major depressive disorder, observed the situation and believed the agitated resident was going to harm the CNA. Acting on this belief, the second resident struck the first resident on the jaw, causing pain that required an x-ray to rule out a fracture. The facility's records and interviews confirmed that the agitated resident was attempting to get up from bed to smoke outside of designated hours, and the CNA intervened to prevent a fall. The second resident, witnessing the interaction, interpreted the agitated resident's behavior as threatening toward the CNA and decided to intervene physically. The staff responded to the incident after hearing a commotion, separated the residents, and later moved the aggressor to another room. The injured resident reported pain and anger following the incident, and the x-ray showed no fracture. Review of facility policies indicated that staff are expected to identify and prevent all forms of abuse, including resident-to-resident abuse, and to notify the charge nurse immediately if there are concerns about resident behavior or policy violations. The policies also require staff training in abuse prevention and management of aggressive resident behavior. In this case, the failure to notify the RN of the resident's agitation and the lack of effective intervention allowed the physical altercation to occur, resulting in harm to a resident.
Failure to Prevent Resident-to-Resident Physical Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for two residents, resulting in one resident being struck by another. On the night of the incident, a resident with a history of blindness, schizophrenia, bipolar disorder, and nicotine dependence became agitated after being denied the opportunity to smoke outside of designated hours. The certified nursing assistant (CNA) attempted to calm the resident and prevent him from getting up due to his fall risk, but did not notify the registered nurse (RN) of the resident's escalating agitation. Another resident, who had blindness in one eye, diabetes, and major depressive disorder, observed the situation and believed the agitated resident was going to harm the CNA. Acting on this belief, the second resident moved in his wheelchair and struck the agitated resident on the jaw. The incident was witnessed by staff, and the two residents were separated. The struck resident experienced jaw pain and required an x-ray, which showed no fracture. Interviews and record reviews confirmed that the facility's staff did not provide adequate supervision to prevent the altercation. The care plan for the agitated resident required monitoring for unsafe smoking practices and immediate notification of the charge nurse if the smoking policy was violated, but this was not followed. The facility's policies also required staff to protect residents from abuse, including resident-to-resident physical aggression, but these measures were not effectively implemented during the incident.
Failure to Implement Fall Prevention Care Plan During Transfer
Penalty
Summary
The facility failed to implement care plan interventions designed to prevent falls for a resident with a history of impaired gait, balance issues, and a high risk for falls. The resident, who was cognitively intact and required substantial assistance with transfers, was admitted with diagnoses including abnormalities of gait and mobility, lack of coordination, and a need for assistance with personal care. The care plan for this resident included interventions such as adapting the environment for safety, anticipating and meeting the resident's needs, and assisting with all transfers or ambulation. Despite these interventions, on the date of the incident, the resident was not properly positioned in the wheelchair after being transferred from the toilet by a CNA, which resulted in the resident sliding off the wheelchair and falling to the floor. Interviews and documentation confirmed that the CNA did not ensure the resident was seated properly in the wheelchair before moving it, and both the LVN and DON acknowledged that the resident was sitting close to the edge of the seat at the time of the fall. The facility's policies emphasized the importance of individualized, resident-centered safety interventions and the implementation of care plan measures to prevent accidents. However, these measures were not followed during the transfer, directly leading to the fall event. The resident did not sustain injuries as confirmed by subsequent x-rays.
Deficient Management and Documentation of Emergency Drug Supplies and Medication Orders
Penalty
Summary
The facility failed to ensure proper management and documentation of emergency drug supplies (E-kits), resulting in several deficiencies. Upon delivery from the pharmacy, the facility did not receive the correct narcotic E-kit and instead received a C-II E-kit, leaving the facility without a narcotic E-kit for approximately 24 hours. Staff interviews and observations revealed that the narcotic E-kit was missing from its designated location, and only C-II E-kits were present. The facility's policy required staff to check medications against pharmacy order sheets and retain a signed delivery receipt, but this process was not followed, leading to the absence of the required narcotic E-kit. Additionally, the facility did not replace the E-kit within 72 hours of first use, as required by policy. Review of the narcotic E-kit logbook showed entries for medication use that were several weeks apart, indicating that the kit was not replaced in a timely manner. The Director of Nursing confirmed that the dates on the log should not be more than 72 hours apart, but this standard was not met. Furthermore, the facility failed to ensure that drug disposition forms were properly completed; seven forms were found with missing dates and nurse signatures, and some lacked a witnessing nurse's signature altogether. The facility also did not adequately follow up on a resident's order for Norco 10-325 mg, a potent opioid, which was pending authorization from the pharmacy. The medication was not available in the resident's medication drawer, and there was no documentation of follow-up with the pharmacy until prompted by the surveyor. The facility's policy required documentation of non-delivery and follow-up, but this was not done for the resident's Norco order.
Failure to Maintain Sanitary Food Storage and Staff Practices in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen. Specifically, the ice scooper holder was found to be dirty during an inspection, despite cleaning logs indicating it had been cleaned. The Dietary Food Nutrition Supervisor (DFNS) confirmed the ice scooper holder should always be kept clean to prevent contamination, and acknowledged that a dirty holder could lead to a break in infection control. Facility policy required all containers used with ice to be kept clean and stored in a sanitary manner. Additionally, staff were found to be storing personal perishable food in the facility's refrigerator and placing personal items, such as a tumbler, in non-designated areas within the kitchen. The DFNS confirmed that personal food and belongings are not allowed in the kitchen or food service production areas, as outlined in the facility's policies. These actions were observed during a kitchen inspection and were acknowledged by the DFNS as violations of facility policy.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement and follow its infection prevention and control program in several key areas. During medication administration observations, a nurse did not don a gown as required by the facility's Enhanced Barrier Precautions (EBP) policy when providing direct care to a resident identified as needing enhanced precautions. The nurse acknowledged forgetting to wear the gown, and both the infection preventionist and another nurse confirmed that medication administration and taking vital signs are considered direct care activities that require the use of gowns and gloves under EBP. The facility's policy specified that EBP is used to prevent the spread of multi-drug-resistant organisms and requires targeted gown and glove use in addition to standard precautions. Additionally, another nurse failed to disinfect the vial top and injection ports with alcohol swabs during the preparation and administration of intravenous vancomycin for a resident. The nurse stated that disinfection was not necessary, which was contradicted by the infection preventionist and the facility's policy. The policy required strict aseptic technique, including disinfecting all injection ports with a sterile alcohol swab for at least 30 seconds before access. The facility's water management plan was also found to be insufficient. The plan lacked essential details such as a description of the building, the population it housed, and a comprehensive description of the water system. It did not identify areas where Legionella could grow and spread, nor did it include control measures or verification steps to ensure the plan was being followed. Interviews with facility leadership confirmed that the water management plan was not personalized or adequate for the facility's needs, and did not meet the requirements outlined in the facility's own policy and procedures.
Failure to Obtain Legal Representative for Severely Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident who was severely cognitively impaired and lacked decision-making capacity had a legal representative to assist with medical decisions. The resident, who had diagnoses including major depressive disorder, schizophrenia, cataracts, and anxiety disorder, was documented in both the Minimum Data Set and History & Physical as being unable to understand or make decisions. Despite this, the facility obtained verbal consent from the resident for psychotropic medication and had the resident sign an Advance Health Care Directive and other documents, with staff acting as witnesses, rather than involving a legal representative. Interviews with staff confirmed that the resident had periods of confusion and limited vision, and that staff were aware of the resident's lack of capacity. The Social Services Assistant acknowledged not knowing the facility's advance directives policy, and the DON confirmed the resident's incapacity. The Medical Director stated that in cases of cognitive decline, a bioethics meeting and possible appointment of a conservator should occur. The facility's policy indicated residents have the right to appoint a legal representative, but this was not followed for the resident in question.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident following a fall incident. The resident, who had a history of Parkinson's disease, encephalopathy, unsteadiness on feet, lack of coordination, and previous falls, was admitted with these diagnoses and was identified as being at risk for falls. The Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and required varying levels of assistance with activities of daily living, but had not experienced any falls since admission until the incident in question. On the date of the incident, the resident experienced a fall and was found sitting on the floor holding onto his walker. The assessment following the fall noted no injuries, and the physician was notified, resulting in an order for an x-ray. Despite this event, a review of the resident's care plan revealed that it had not been updated or revised to reflect the fall or to include any new interventions. The last revision to the care plan had occurred several months prior to the fall. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the care plan should have been updated after the fall to include additional interventions and ensure staff were aware of the necessary care. The facility's policy also required care plans to be reviewed and updated after significant changes in a resident's condition, such as a fall. The failure to update the care plan after the resident's fall constituted the deficiency identified in the report.
Failure to Provide Effective Oral Hygiene Care for Dependent Resident
Penalty
Summary
The facility failed to provide effective oral hygiene care for a resident who was dependent on staff for all activities of daily living, including oral care. The resident had significant medical conditions, including dysphagia, a gastrostomy tube, and malnutrition, and was assessed as having severely impaired cognitive skills and poor memory. The care plan specified that oral care should be provided three times daily, but observations revealed the resident had a tan substance on her teeth, dry lips, and a substance on her reddened, swollen tongue. Interviews with staff indicated that oral care was being performed only twice daily, and the CNA acknowledged that the resident's mouth had appeared in poor condition for some time. The RN confirmed the poor state of the resident's mouth and indicated that such a condition would warrant notifying a physician and seeking further interventions. The dental hygienist, who had seen the resident recently, noted difficulty in providing care due to the resident's lack of cooperation and was unable to confirm whether consistent oral care was being provided. Subsequent observations showed some improvement in the resident's oral condition, but documentation and interviews confirmed that the facility's policy of maintaining moist lips and oral tissues and preventing oral infection was not consistently followed. The DON stated that daily oral care is especially important for residents with g-tubes and acknowledged that the observed condition of the resident's mouth was unacceptable.
Failure to Lock Bed and Hoyer Lift During Resident Transfer
Penalty
Summary
Certified Nursing Assistants (CNA2 and CNA3) failed to lock both the bed and the Hoyer lift before placing the sling under a resident with a history of hemiplegia, hemiparesis, cerebral infarction, aphasia, and previous falls. The resident's care plan specifically required a safe environment with bed wheels locked and assistance with all transfers due to impaired gait, balance, and mobility. During the observed transfer, neither the bed nor the Hoyer lift was locked, contrary to the care plan and facility policy. Interviews with the involved CNAs, a Licensed Vocational Nurse, and a Registered Nurse confirmed that both the bed and the Hoyer lift should have been locked to ensure safety and prevent accidents. The facility's policy on using mechanical lifts also required staff to ensure the lift was stable and locked before use. The failure to follow these procedures was directly observed and acknowledged by staff, representing a lapse in implementing required safety measures for the resident.
Failure to Complete Required Bowel and Bladder Assessments
Penalty
Summary
The facility failed to perform a quarterly bowel and bladder assessment for a resident as required by the resident's care plan. The care plan specified that assessments should be completed on admission, quarterly, and as needed, but documentation showed that the last assessment was performed on 2/14/2025, with no subsequent assessments recorded. This omission was confirmed during interviews with both a registered nurse and the Director of Nursing, who acknowledged that the quarterly assessment had not been completed as required. The resident involved had multiple medical diagnoses, including congestive heart failure, cirrhosis of the liver, reduced mobility, and adult failure to thrive. The resident was cognitively intact, able to make needs known, and required substantial assistance with toileting hygiene. The resident was frequently incontinent of both bowel and bladder, and the care plan included a goal to prevent complications from incontinence, such as skin breakdown or infection. Despite these needs, the required ongoing assessments to monitor and manage the resident's continence status were not performed according to the care plan schedule. Facility policy and procedure documents indicated that comprehensive, person-centered care plans should be developed and implemented for each resident, including measurable objectives and timeframes. The policies also required ongoing assessment and management of urinary continence and incontinence, with regular documentation and review. The failure to follow these policies and the resident's care plan resulted in a deficiency related to the lack of timely bowel and bladder assessments.
Failure to Label G-Tube Flush Bag for Resident Receiving Enteral Feeding
Penalty
Summary
A deficiency was identified when a resident with a history of aphasia, dysphagia, and malnutrition, who was dependent on gastrostomy tube (g-tube) feeding, was observed to have a flush bag attached to their g-tube pump that was not labeled with the date, time, and nurse's initials. The resident's care plan specifically required that the formula container, syringe, and administration set be labeled with the resident's name, date, time, and nurse's initials. During observation and interview, both the treatment nurse and an LVN confirmed that the flush bag was not labeled as required. Further interviews with the LVN and the Director of Nursing confirmed that the lack of labeling on the flush bag could result in not knowing when the flush was hung and could pose a risk of infection. Review of the facility's policy indicated requirements for labeling the formula but did not specifically address labeling of the flush bag. The failure to label the flush bag as outlined in the resident's care plan constituted the deficiency.
Failure to Administer and Document Physician-Ordered Medication for Allergic Reaction
Penalty
Summary
The facility failed to administer medication as ordered by the physician for one resident. The resident, who was admitted with diagnoses including fibromyalgia and disturbances of skin sensation, experienced facial itching due to a possible allergic reaction. The resident was cognitively intact and required varying levels of assistance with activities of daily living. On the date of the incident, the resident complained of facial itching, and a Change in Condition Evaluation was completed. The primary physician was notified and gave an order to administer Benadryl 25 mg orally every six hours for 14 days as needed for itching. This order was documented in the resident's physician order and care plan, which included the intervention to administer Benadryl as needed for itching. However, review of the Medication Administration Record (MAR) showed that the Benadryl was not signed as given on the date of the incident. The resident later stated in a telephone interview that she did not receive the Benadryl. The LVN involved stated she administered the medication, but there was no documentation to support this. Both the registered nurse supervisor and the director of nursing confirmed during interviews and record reviews that the MAR was not signed and there was no other documentation indicating the medication was given. Facility policy requires that the individual administering medication must document the administration on the MAR, including date, time, dosage, route, symptoms, results, and signature. The lack of documentation and failure to administer or record the administration of Benadryl as ordered constituted the deficiency.
Failure to Post Actual Staff Hours as Required
Penalty
Summary
The facility failed to comply with the federal requirement to post the actual hours worked by staff daily in an area accessible to the public. On the observed day, the Direct Care Services Hours Per Patient Day (DHPPD) actual hours were not posted, only the projected hours were displayed. This deficiency was identified during an observation on 11/12/2024, where it was noted that the DHPPD for the previous day (11/11/2024) was also missing. Interviews with the Director of Staff and Development (DSD) and the Director of Nursing (DON) revealed a misunderstanding of the posting requirements. The DSD was unsure if actual hours needed to be included, while the DON initially believed only projected hours were necessary. However, upon reviewing the facility's policy, the DON acknowledged that actual hours for the previous day should have been posted alongside the current day's projected hours. The facility's policy clearly stated that shift staffing information, including actual hours worked, must be recorded and maintained for 24 hours in a single location.
Failure to Administer Pomalyst as Prescribed
Penalty
Summary
The facility failed to implement a consistent and accurate system for reconciling the administration of Pomalyst, an oral chemotherapeutic capsule prescribed for a resident with multiple myeloma. This failure resulted in the resident missing two doses of the medication on specified dates. The resident, who was admitted with multiple diagnoses including multiple myeloma, type 2 diabetes mellitus, and end-stage renal disease, was prescribed Pomalyst to be taken on specific days. However, the medication was not administered as ordered, leading to missed doses. During interviews, it was revealed that the resident was aware of the prescription but reported not receiving the medication as prescribed. The Director of Nursing confirmed the missed doses upon reviewing the Medication Administration Record. An LVN admitted to not administering the medication on one occasion due to being unable to locate it in the medication cart. The pharmacist emphasized the importance of administering Pomalyst as prescribed to avoid potential side effects. The facility's policy indicated that medications should be administered safely, timely, and as prescribed, which was not adhered to in this case.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure dignity and respect for two residents, resulting in a deficiency related to resident rights. Resident 2, who was admitted with conditions including hypertension, low back pain, anemia, and cellulitis, reported an incident where a CNA yelled at them and another resident for questioning the care provided. This incident occurred after Resident 2 assisted another resident who was cold and uncovered. Resident 2 expressed that staff frequently yelled during the night shift, which was inappropriate behavior. Resident 7, who was admitted with osteoarthritis, anemia, reduced mobility, and lack of coordination, corroborated the occurrence of yelling, having heard an argument involving multiple people around the same time as Resident 2's incident. Both residents had intact cognition and required varying levels of assistance from staff for daily activities. The facility's policy on resident rights, revised in 2016, mandates that employees treat all residents with kindness, respect, and dignity, which was not adhered to in these instances.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide necessary care and services to a resident with multiple medical conditions, including an amputation site, acute respiratory failure with hypoxia, and an arterial ulcer on the right lower leg. The facility did not assess or document the condition of the resident's arterial ulcer upon admission, nor did they develop a comprehensive care plan that included the physician's order for treatment of the ulcer. The treatment order, which required daily care for 21 days, was not followed, resulting in the resident not receiving treatment for over two weeks. Additionally, the facility did not adequately monitor the resident's respiratory status as per the continuous oxygen therapy care plan. There were discrepancies in the documentation of the resident's oxygen saturation levels, and the facility failed to administer the correct amount of oxygen as required. This lack of proper monitoring and treatment contributed to the resident's transfer to a general acute care hospital, where they presented with altered levels of consciousness, shortness of breath, and right ankle pain. The resident's condition deteriorated further at the hospital, where they were diagnosed with soft tissue ulceration with underlying osteomyelitis, pulmonary edema, and adjacent atelectasis. Despite the hospital's efforts, the resident passed away three days after the transfer. Interviews with facility staff revealed that the treatment order was incorrectly documented, and the care plan was not initiated upon admission, leading to a lack of interventions for the resident's wounds.
Failure to Administer Medication Leads to Resident Weight Loss
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident 78, who was at risk for malnutrition. Resident 78 did not receive 17 doses of Megestrol Acetate Suspension, an appetite stimulant, as ordered by the physician. This failure was due to the medication not being available in stock, and the facility did not maintain accurate medication administration records. The medication was marked as administered on multiple occasions when it was not available, leading to significant weight loss for the resident. Resident 78 was admitted with several diagnoses, including an intracranial abscess, hearing loss, and gastroesophageal reflux disease. The resident had intact cognition and required assistance with activities of daily living. Despite being at risk for malnutrition, as indicated by a Mini Nutrition Evaluation score, the facility's interventions to administer the appetite stimulant were not followed. The medication administration records inaccurately reflected that the medication was given, even though it was not in stock, as confirmed by interviews with the nursing staff and the Director of Nursing. The facility's policies and procedures required that medications be administered according to prescriber orders and documented immediately after administration. However, the facility failed to adhere to these policies, resulting in Resident 78 experiencing more than a five percent weight loss in one month. The Registered Pharmacist confirmed that the medication was requested but not delivered until a later date. Interviews with the nursing staff revealed a lack of awareness and adherence to proper documentation practices, contributing to the deficiency.
Failure to Label and Date Stored Food
Penalty
Summary
The facility failed to ensure that food stored in the kitchen was properly labeled and dated, which could potentially lead to food-borne illnesses for all residents receiving food from the kitchen. During an initial kitchen tour, surveyors observed several items in the walk-in refrigerator that were unlabeled and undated, including unopened and opened bags of whole wheat bread, hamburger buns, and various frozen vegetables such as broccoli, spinach, mixed vegetables, peas, carrots, and cauliflower. The Dietary staff confirmed that these items were not labeled or dated, acknowledging that all food stored in the kitchen should be labeled and dated to track their usability and prevent food-borne illnesses. The Director of Nurses also confirmed that all food stored in the kitchen should be labeled and dated to ensure the safety of the residents. A review of the facility's policy and procedure on labeling and dating foods indicated that all food items in storage areas, including the storeroom, refrigerator, and freezer, need to be labeled and dated. The policy specifies that food delivered to the facility should be marked with a received date, and newly opened food items should be labeled with an open date and a use-by date according to various storage guidelines. This deficiency highlights a failure to adhere to the facility's established procedures for food safety.
Failure to Develop Individualized Care Plan for Resident with Diabetes
Penalty
Summary
The facility failed to develop an individualized person-centered care plan for a resident, identified as Resident 40, who was admitted with diagnoses including Type II diabetes, unsteadiness on feet, and major depressive disorder. Despite the resident's condition requiring specific interventions, the facility did not create a care plan addressing hyperglycemia after a significant change in the resident's condition was noted. On 3/7/2024, Resident 40 experienced an elevated and uncontrolled blood sugar level of 495 mg/dl, yet no care plan was developed to manage this condition. Interviews with the Registered Nurse Supervisor and the Director of Nursing revealed that licensed staff were required to develop and implement care plans with appropriate interventions following a change in a resident's condition. However, this was not done for Resident 40, leading to a lack of care and monitoring. The facility's policy indicated that care plans should be revised as residents' conditions change, but this was not adhered to in this case, resulting in the deficiency.
Failure to Document and Monitor Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a right heel deep tissue injury (DTI) as per the comprehensive assessment and professional standards of practice. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was admitted with a diagnosis of pressure-induced deep tissue damage. The care plan for the resident, initiated shortly after admission, included interventions to monitor and document changes in the wound's condition, such as color, drainage, odor, sensation, and pain, as well as weekly measurements of the wound. However, these interventions were not implemented for a period of 16 days. During this period, there was no documentation in the resident's medical record or the Treatment Administration Record (TAR) regarding the condition of the right heel DTI. This lack of documentation included essential details such as the wound's color, drainage, odor, sensation, and measurements, which were required by the care plan. Observations and interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed the absence of documentation and highlighted the potential risk of infection or worsening of the wound due to this oversight. The facility's policies and procedures for charting, documentation, and wound care required detailed recording of treatment and assessment data, including the date and time of procedures, assessment findings, and the resident's response to treatment. Despite these requirements, the facility did not adhere to its own policies, resulting in a failure to track the resident's progress and potentially compromising the resident's care.
Failure to Implement and Update Fall Prevention Plan
Penalty
Summary
The facility failed to implement and update the Risk for Falls Care Plan for a resident with a history of falls, identified as Resident 64. The care plan, dated 12/5/2023, included interventions such as a yellow star on the wall above the headboard, a gold star on the name plate, a yellow fall risk wristband, yellow non-skid socks, and a yellow star on the wheelchair. These interventions were not implemented, as observed on 5/8/2024, when the resident was seen without the required fall prevention items. Additionally, the care plan was not revised following a fall on 2/16/2024, which resulted in a skin abrasion on the resident's right anterior forearm. The facility's policy on Falls and Fall Risk Management, revised in 3/2018, requires a resident-centered fall prevention plan to be implemented and updated as needed. However, the care plan for Resident 64 was not updated after the fall, and the interventions were not in place, as confirmed by the Director of Nursing during an interview. The facility's policy on comprehensive person-centered care plans, revised in 7/2017, also mandates that care plans be revised when there is a significant change in a resident's condition, which was not adhered to in this case.
Failure to Properly Label and Store Nasal Cannula Tubing
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not ensuring the nasal cannula (NC) tubing was labeled and stored in a plastic bag. The resident, who was admitted with acute respiratory failure with hypoxia and dependence on supplemental oxygen, had a care plan that required continuous oxygen therapy at two liters per minute via NC to maintain oxygen saturation above 93%. Observations revealed that the NC tubing was not labeled and was improperly stored, either hanging over a tube feeding machine or placed inside a bedside drawer. Interviews with staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON), confirmed that the NC tubing should have been labeled with the date and stored in a plastic bag to prevent contamination and infection. The facility's policy indicated that the oxygen cannula and tubing should be changed every seven days or as needed and stored in a plastic bag when not in use. The failure to adhere to these protocols put the resident at risk for infection and complications associated with oxygen therapy.
Lack of Justification for Continued Antidepressant Use
Penalty
Summary
The facility failed to provide documented justification for the continuation of the antidepressant medication Effexor beyond 30 days for a resident diagnosed with major depressive disorder, among other conditions. The resident was admitted with diagnoses including major depressive disorder, osteoarthritis, and difficulty in walking. The care plan for the resident included administering medications as ordered and monitoring for side effects and effectiveness, but there was no review date indicated for the goal of being free of depression symptoms. The resident received Effexor daily, and there were no episodes of verbalization of sadness recorded during this period. The Consultant Pharmacist's Medication Regimen Review (MRR) from January to April did not include any recommendations, actions, or rationale for the continued administration of Effexor. The facility's policy required the consultant pharmacist to review each resident's medication regimen monthly and report any non-life-threatening medication irregularities to the attending physicians. However, there was no documentation of a Gradual Dose Reduction (GDR) for the resident, which the Director of Nurses acknowledged as important to ensure the necessity of the prescribed medications.
Medication Error Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically by not having the medication Megestrol Acetate Oral Suspension available for administration for 17 days. This medication was prescribed to stimulate the resident's appetite, and its absence led to significant weight loss. The resident, who was admitted with various medical conditions including intracranial abscess and gastroesophageal reflux disease, was at risk for malnutrition due to the lack of medication. During a medication pass observation, it was noted that the medication was not available in the medication cart, and the Licensed Vocational Nurse (LVN) inaccurately marked the medication as administered. This error was repeated by multiple nurses over the course of several days, as documented in the Medication Administration Record (MAR). The Director of Nursing (DON) confirmed that the medication was not delivered until much later, and the Registered Pharmacist corroborated that the medication was requested but not delivered until a later date. Interviews with staff and the resident's representative revealed that the resident had not been eating well and experienced a significant weight loss from 182 pounds to 156 pounds. The Registered Dietician noted that the resident's oral intake was initially stable but declined due to the lack of the appetite stimulant and ongoing antibiotic treatment. The facility's policies on medication administration and documentation were not followed, contributing to the deficiency.
Improper Storage of Ophthalmic Solution
Penalty
Summary
The facility failed to ensure the safe storage of Dorzolamide-Timolol Ophthalmic Solution, a medication used to treat high pressure in the eyes, for a resident. During an observation and interview, it was found that the medication was stored in a refrigerator at 40 degrees Fahrenheit, contrary to the manufacturer's requirement of storing it between 68 to 77 degrees Fahrenheit. The Licensed Vocational Nurse (LVN) acknowledged the improper storage and indicated that the medication should not have been refrigerated, as this could render it ineffective. The Director of Nursing (DON) confirmed that the Dorzolamide-Timolol should not have been stored in the refrigerator, as improper storage could lead to the medication being ineffective in treating elevated eye pressure. The facility's policy on medication storage, dated April 2019, requires that drugs and biologicals be stored under proper temperature, light, and humidity controls, which was not adhered to in this instance.
Failure to Adjust Laxative Administration for Resident with Loose Stools
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident experiencing a change in bowel condition, specifically frequent loose stools. The resident, who was admitted with multiple medical conditions including multiple myeloma, malnutrition, and dependence on renal dialysis, was prescribed MiraLAX, a laxative, to be taken every 12 hours for constipation. Despite the resident experiencing frequent loose stools, the facility continued administering the laxative without notifying the physician or adjusting the treatment plan. The resident's medical records indicated frequent loose bowel movements over several weeks, yet there was no documentation of the physician being informed of this change in condition until much later. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's diarrhea, with some staff members unaware of the resident's condition or the need to adjust the laxative dosage. The Director of Nursing acknowledged that the resident should not have been given MiraLAX with loose stools and that the physician should have been notified sooner. The facility's policies required prompt notification of changes in a resident's condition, but this was not adhered to in this case. The resident's diarrhea was eventually linked to chemotherapy and dialysis, and the laxative was deemed unnecessary. The failure to address the resident's change in condition in a timely manner posed a risk of dehydration and other complications, highlighting a deficiency in the facility's care and communication processes.
Failure to Review Transfer Records Leads to Missed Appointments
Penalty
Summary
The facility failed to thoroughly review the transfer records from the general acute hospital (GACH 1) for a resident admitted on 3/16/24. The resident had multiple follow-up appointments arranged by GACH 1 for vascular diagnostics, chemotherapy, and consultations with a hematologist and pulmonologist. However, the facility did not review the inpatient progress notes that contained these appointments. Instead, the admitting registered nurse (RNS) only reviewed the medication pages to transcribe the admission orders and verify them with the resident's primary physician. This oversight resulted in the resident missing several critical medical appointments scheduled between 3/18/24 and 4/25/24. Interviews with the director of nursing (DON) and RNS 1 revealed that GACH 1 did not inform the facility about the resident's appointments during the pre-admission report. The facility's policies on charting, documentation, and admission were reviewed, indicating that documentation should be complete and accurate, and preliminary resident information should be documented upon admission. Despite these policies, the failure to review the transfer records thoroughly led to a delay in the resident's treatment for multiple myeloma, anemia, and other conditions requiring substantial assistance with daily activities.
Failure to Safeguard Resident's Personal Funds
Penalty
Summary
The facility failed to safeguard personal funds for one resident. The Licensed Vocational Nurse (LVN) retrieved $800 from the resident and placed the money in the narcotic box instead of following the proper procedure. The resident, who was cognitively intact and required maximum assistance with daily activities, had been admitted with $900, of which $100 was kept in their wallet and $800 was stored in the medication cart by staff. The Social Services staff observed the $800 in the medication cart the following day, but it was not removed and placed in the business office until two days later. The facility's policy required that the money be transferred to the business office on the next available business day, with the transaction requiring two signatures. The delay in transferring the funds and improper initial storage in the narcotic box led to the potential risk of the resident's personal funds being stolen or misused.
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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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