Park Avenue Healthcare & Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pomona, California.
- Location
- 1550 North Park Avenue, Pomona, California 91768
- CMS Provider Number
- 555852
- Inspections on file
- 113
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Park Avenue Healthcare & Wellness Center during CMS and state inspections, most recent first.
A resident with dementia and a financial POA had family members request a medical update, which the SSD and SSC denied after the responsible party instructed staff not to share information, without asking the resident for consent. Although documentation showed the resident could express needs, staff relied solely on the responsible party and the admission record, did not consult the resident about sharing medical information, and later the resident reported sadness and confirmed that the family members were allowed to receive updates.
Staff denied further visitation by two family members after a responsible party instructed the facility not to allow them to visit or receive medical updates, without confirming the resident’s own wishes. The resident, who had dementia but could express needs, later stated that these and other family members were allowed to visit and became sad upon learning they had been barred. The SSD acknowledged that facility policy allows family visitation based on the resident’s wishes and that staff should have asked the resident, but instead followed the responsible party’s directive contrary to the written visitation policy.
A resident with heart failure, hypertension, and a cardiac pacemaker had an existing care plan addressing altered cardiovascular status and monitoring for chest pain, but when the family brought in a heart monitor for ongoing pacemaker monitoring, staff did not revise the care plan to include this device. Progress notes documented the family’s instructions to plug in and place the monitor near the resident, yet no care plan interventions, monitoring frequency, or safety precautions related to the pacemaker monitoring system were added, contrary to facility policies on pacemaker management and complete, accurate medical records. The ADON, RN, and DON all acknowledged that the care plan was not updated despite the importance of this information for guiding care.
A cognitively intact resident with heart failure, HTN, and a cardiac pacemaker returned from a cardiology visit with a pacemaker monitoring device (PMD) provided by a family member. An RN plugged in and placed the PMD near the resident per the family member’s instructions but did not contact the physician or cardiologist for orders or usage instructions. Subsequent review with the DON and ADON showed there were no orders or instructions for the PMD in the paper or electronic chart, and the resident’s pacemaker/PMD information was not readily accessible in the record as required by the facility’s pacemaker management policy and education materials.
A resident with dementia and diabetes, requiring moderate assistance with eating, had multiple instances of missing meal intake percentage documentation over several days. Staff interviews confirmed that documenting meal intake was required, and facility policy mandated complete and accurate records for care provided.
A resident with cognitive impairment and chronic health conditions was found living in an unclean environment, with brown spots on the wall and brown smears on a recliner chair in their room. Observations and staff interviews confirmed the lack of cleanliness, which did not align with the facility's housekeeping policies.
A resident with multiple complex medical conditions was admitted without timely medication orders due to a lack of response from the attending physician and failure by the RN to escalate the issue to the Medical Director. This resulted in a delay in obtaining and administering essential medications as required by facility policy.
A resident with type 2 diabetes and hyperglycemia was not provided with a physician-ordered diabetic diet as required. Instead, an RN mistakenly ordered a regular diet, despite hospital discharge instructions specifying a diabetic diet. Both the RN and DON acknowledged the importance of the correct diet for the resident's medical needs.
Surveyors found that a resident did not receive appropriate care for bowel/bladder continence or incontinence, catheter management, and UTI prevention. The facility failed to provide adequate attention to continence needs, proper catheter care, and sufficient infection control measures.
Milk was left at room temperature for more than two hours for three residents with moderate cognitive deficits and various medical conditions, despite facility policy requiring dairy to be refrigerated until use. The Dietary Services Supervisor confirmed the practice and acknowledged the risk of bacterial growth if milk is not consumed or disposed of within the recommended timeframe.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Surveyors observed water dripping from the condenser fans of a commercial refrigerator onto food items such as juice, water, and salads prepared for residents. The Dietary Services Supervisor and Assistant Maintenance Director confirmed the equipment was not functioning properly and that this situation could lead to food contamination.
A resident with dementia and severe cognitive impairment repeatedly requested milk, but a CNA did not provide it or seek assistance, despite facility policy requiring that meals and snacks be offered according to individual preferences. The resident's bedside lacked both milk and water, and the CNA cited previous breakfast service and the need for thickened liquids as reasons for not fulfilling the request.
A resident with diagnoses of depression, schizoaffective disorder, and schizophrenia was admitted and screened positive for SMI on the PASARR Level I assessment. The facility did not respond to multiple attempts by DHCS to arrange a required PASARR Level II screening, resulting in the evaluation not being scheduled in a timely manner and the resident not being assessed for specialized services.
The facility did not consistently implement or document care plan interventions for two residents: one with chronic pain and another at risk for bleeding due to anticoagulant therapy. Pain characteristics were not recorded as required when pain medication was given, and a care plan addressing bleeding risk was not developed despite a known drug interaction and a change in condition. These failures resulted in unmet individualized needs for both residents.
Two residents did not receive necessary care as ordered: one was not monitored for bleeding while on anticoagulant therapy despite a known drug interaction and prior episodes of blood in the urine, and another experienced a significant delay in follow-up for an infectious disease consult for recurrent UTIs, resulting in unmanaged symptoms and distress.
A resident with moderate cognitive impairment and multiple diagnoses reported missing glasses to the SSA, who made an initial call to optometry but did not follow up or provide updates. The resident, who relied on the glasses for reading, felt frustrated and ignored due to the lack of timely action and communication.
Two residents were not provided with an environment free from accident hazards: one high-fall-risk resident's bed was left in a high position against care plan instructions, and another resident was allowed to keep cigarettes and a lighter in their room despite facility policy and the presence of nearby residents on oxygen. Staff interviews and documentation confirmed these lapses in following established safety protocols.
A resident receiving enteral feeding via gastrostomy tube experienced a prolonged alarm indicating a tube block, which staff did not address for nearly half an hour. The resident, who was cognitively intact and dependent on staff for care, expressed frustration at the ongoing alarm. Nursing staff acknowledged the alarm should have been checked sooner and recognized the importance of addressing such alarms to prevent complications.
A resident with a tracheostomy and chronic respiratory failure did not receive physician-ordered oxygen therapy when the tracheostomy mask was found positioned on the side of the neck instead of over the stoma, with a loose trach tie. Staff confirmed that the mask was not properly placed, preventing effective oxygen delivery as required by the care plan and facility policy.
A CNA did not receive a required annual performance evaluation, and the most recent evaluation was not signed by the CNA. The facility lacked a formal policy for annual staff performance evaluations, and interviews confirmed the CNA had not received or signed an evaluation in the previous year.
A resident with multiple medical conditions did not have pharmacist recommendations regarding PRN Tylenol orders for pain management acted upon or documented by staff or the prescriber. Despite repeated recommendations to address all levels of pain in the medication regimen, the facility failed to update or document changes in the resident's records, contrary to facility policy.
A resident with quadriplegia and cerebral palsy did not have required Restorative Nursing Aide (RNA) services properly documented, as per facility policy. Although PROM exercises and hand roll applications were ordered to be performed five times weekly, documentation was missing for one day, with no explanation provided. The RNA later stated that services were completed but not entered into the charting system, and the DON confirmed that accurate documentation was required.
A resident with significant physical dependence and intact cognition was found with their call light on the floor, out of reach. Both an LVN and the DON confirmed the device should have been accessible, and facility policy requires call lights to be within reach. This failure resulted in a deficiency.
A resident with diabetes, Alzheimer's disease, and dementia repeatedly refused blood glucose checks, and staff did not notify the physician as required by the care plan and facility policy. Nursing staff and the Quality Assurance Nurse confirmed that the physician was not informed of these refusals, despite documentation in the MAR.
Staff did not follow the care plan for a resident with severe cognitive impairment by failing to notify the physician after repeated refusals of accu checks, despite multiple documented instances of refusal and a clear directive in the care plan to do so after three attempts.
A resident with mobility limitations and intact cognition was permitted to leave the facility overnight without a documented physician order, contrary to facility policy. The responsible nurse claimed to have received a telephone order but failed to document it, and the physician later denied or could not recall giving such an order. The resident returned with multiple injuries and signs of intoxication, and was subsequently hospitalized for alcohol intoxication and a closed head injury.
A resident with an indwelling Foley catheter and a pressure injury did not receive wound care as ordered by the physician. Staff observed that the wound on the resident's penis was not covered with a dressing as required, and interviews with nursing staff confirmed the dressing was missing during care. Facility policy required treatments to be provided as ordered, but the wound was left uncovered.
A resident with mobility limitations and intact cognition left the facility for an overnight pass without a documented physician's order, as required by policy. Nursing staff claimed to have received a verbal order but did not document it, and the physician later denied authorizing the pass. The resident returned with multiple injuries and signs of intoxication, highlighting a failure to maintain complete and accurate medical records.
A resident with severe cognitive impairment physically assaulted two other residents, causing facial injuries, a closed head injury, and neck redness. Both victims had dementia and were unable to protect themselves. Staff and documentation confirmed the aggressor's actions were willful and constituted abuse, indicating a failure to ensure resident safety and prevent abuse as required by facility policy.
Multiple residents with significant care needs, including those with fall risk, cognitive impairment, and chronic medical conditions, experienced prolonged delays in staff response to call lights, especially during the night shift. These delays led to unmet care needs and, in one case, a resident fell while attempting to seek help independently after waiting an extended period without staff assistance.
A resident with a history of falls waited an hour for staff to respond to a call light before attempting to transfer to a wheelchair and falling, despite care plan instructions for prompt assistance. In a separate event, two residents with severe cognitive impairment were physically assaulted by another resident in quick succession due to lack of adequate supervision after the initial altercation. Staff interviews and facility policies confirmed that required supervision and interventions were not implemented, resulting in preventable injuries.
A resident with severe cognitive impairment and multiple mental health diagnoses was struck in the head multiple times by another resident, resulting in facial contusions and a closed head injury. Despite this significant change in condition, staff did not develop or implement an individualized care plan to address the injury, as confirmed by both the Medical Records Supervisor and DON.
A resident with severe cognitive impairment and high fall risk was admitted without a care plan or inclusion in the fall management program, despite facility policy requiring such measures. Staff were unaware of the resident's fall risk status, and no interventions were in place. The resident subsequently fell out of bed and sustained a skin tear.
A resident with severe cognitive impairment and high fall risk was not provided with a care plan or included in the fall management program after assessment. As a result, staff were unaware of the resident's fall risk status and necessary interventions, leading to a fall from bed and a skin tear injury.
A resident with severe cognitive impairment and mobility limitations experienced a fall, but the subsequent Fall Risk Assessment (FRA) was inaccurately completed by an RN, failing to document the recent fall and incorrectly lowering the resident's fall risk status. This documentation error was confirmed by facility staff and did not prompt an updated care plan for fall risk, contrary to facility policy.
The facility failed to promptly respond to call lights for three residents, violating its policy on communication and call systems. A resident with mobility issues reported waiting up to an hour for assistance, while another with quadriplegia had to call a family member for help due to unresponsive staff. A third resident also experienced long waits during the night shift. The Director of Nursing acknowledged the importance of immediate responses to maintain resident dignity.
The facility failed to provide meals that were palatable and attractive, as observed in two residents. One resident reported mushy and flavorless green beans, while another found their meal unappealing due to presentation. The Dietary Manager confirmed the meals did not meet the facility's standards for attractiveness.
A resident with atrial fibrillation, COPD, and type 2 diabetes reported not receiving meals according to the facility's menu, instead being served a corn dog, rice, and a flour tortilla. The facility's policy requires meals to meet nutritional needs and adhere to set guidelines, but deviations from the menu reportedly occurred about twice a week.
A facility failed to notify the Ombudsman in a timely manner regarding a resident's discharge. The resident, with conditions such as aphasia and hemiplegia, was discharged without the Ombudsman receiving the Notice of Proposed Transfer and Discharge (NPTD) until after the discharge date. The facility's policy requires prior notification, but the Social Services Director could not confirm who sent the NPTD.
A facility failed to maintain complete and accurate clinical records for two residents during medical emergencies. For one resident, an LVN did not document the names of staff involved in a rapid response or CPR, and omitted details of the resident's condition. For another resident, the CIC lacked documentation of staff involvement and attempts to start an IV. The facility's policies require thorough documentation, which was not adhered to in these cases.
The facility failed to prevent and control the spread of influenza, resulting in several residents not being offered or receiving the flu vaccine. This led to multiple residents being diagnosed with the flu and some being hospitalized with severe complications such as sepsis and pneumonia. The facility lacked a system to track vaccination status, contributing to the deficiency.
A facility failed to accurately document flu vaccine consent for several residents, leading to a flu outbreak. The Infection Preventionist falsified records, claiming residents' responsible parties declined the vaccine without actual communication. This resulted in residents not being offered the vaccine, contributing to hospitalizations due to severe flu complications. The facility lacked a proper system to track vaccination status, and the Director of Nursing acknowledged the falsification as a patient safety issue.
Two CNAs failed to follow infection control protocols by not wearing PPE or performing hand hygiene when entering the rooms of residents on Enhanced Barrier Precautions (EBP). These residents, with chronic respiratory failure and tracheostomy, were at increased risk for infection. Observations showed CNAs engaging in patient care without appropriate PPE, despite facility policies requiring such measures to prevent the spread of infections.
The facility failed to follow infection control practices, with staff not wearing appropriate PPE or performing hand hygiene when caring for COVID-19 positive residents. Additionally, residents were not masked outside their rooms, contributing to the spread of infection.
A resident in a long-term care facility was identified as being at risk for elopement after expressing a desire to go home, but no comprehensive care plan was developed to address this risk. The resident was moved to a locked unit typically for those with serious mental health conditions, despite not having such diagnoses. Staff interviews revealed inconsistencies in assessing the resident's elopement risk, and the Director of Nursing confirmed the absence of a necessary care plan.
A resident with a history of seizures was found without padded side rails on their new bed, despite having severe cognitive impairment and a history of tremors. Facility staff later provided padded side rails after observation, but initial oversight posed a risk to the resident's safety.
The facility failed to ensure call lights were within reach for two residents, potentially delaying care. One resident with cognitive impairment and fluctuating decision-making ability had their call light clipped to the wall, while another with severe cognitive impairment had theirs on the floor. Staff confirmed the importance of accessible call lights, as per facility policy.
The facility failed to update care plans for two residents, one with significant weight loss and another after a fall. Despite increased snacks for the first resident and a fall incident for the second, care plans were not revised to include necessary interventions, contrary to facility policies.
A resident with a G-tube experienced a medication administration issue when an LVN failed to follow the facility's policy for handling a clogged G-tube. Despite the tube being clogged for over 30 minutes, the LVN did not notify a supervisor or physician, contrary to the facility's procedures. The resident, who was dependent on staff for daily activities, had a history of gastrostomy-related issues. Interviews revealed that the LVN typically attempted to clear clogs without seeking help, which was not in line with the facility's policy.
Failure to Honor Resident’s Right to Designate Recipients of Medical Information
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s responsible party did not make undelegated decisions and to honor the resident’s right to determine who could receive medical information. The resident was originally admitted with diagnoses including a UTI and unspecified dementia. The H&P documented that the resident could make needs known but could not make medical decisions, and the MDS showed impaired cognitive skills for daily decision-making, with the resident requiring partial to moderate assistance for ADLs. The facility’s records indicated the resident had a responsible party designated under a financial POA, not a medical POA. On a specific date, two family members visited the resident and requested a medical update from the SSD. The SSD, noting the family members were not listed on the admission record, denied the request after contacting the responsible party, who instructed the facility not to provide medical updates to those family members. The SSC confirmed they did not ask the resident for permission to share information with the family members. In a subsequent interview, the resident stated they were unaware that the family members had been denied medical updates, expressed sadness, and affirmed that these family members could receive medical information, stating that their family members were their life. The SSD later acknowledged that the POA on file was financial only and did not authorize medical decision-making, and that the facility should have asked the resident about their wishes, consistent with the facility’s Resident Rights policy.
Failure to Honor Resident Visitation Rights Over Responsible Party Objection
Penalty
Summary
The facility failed to honor a resident’s right to receive visitors of their choosing when family members were denied further visitation based on instructions from the resident’s responsible party (RP) without confirming the resident’s wishes. The resident had been admitted with diagnoses including a UTI and unspecified dementia, and documentation indicated the resident could make needs known but could not make medical decisions and had impaired cognitive skills for daily decision-making. During a visit, two family members requested a medical update from the Social Service Director (SSD). After the SSD spoke with the RP, the RP instructed the facility not to provide medical updates or allow further visitation by these two family members. The facility then denied these family members further access to the resident. In subsequent interviews, the resident stated that the two family members, as well as any family members, had permission to visit and later expressed sadness upon learning that these family members had been denied visitation, stating that family members were their life, with tears observed. The SSD acknowledged that facility policy was to allow any family members to visit when residents permit it and that staff should have asked the resident whether the two family members were allowed to visit. The facility’s written visitation policy stated that residents may receive visitors subject to the resident’s wishes and the protection of other residents’ rights and safety. Despite this policy, staff relied solely on the RP’s direction and did not consult the resident, resulting in the violation of the resident’s visitation rights and the resident not receiving visits from the two family members.
Failure to Update Care Plan for Pacemaker Monitoring System
Penalty
Summary
The facility failed to revise and update the care plan for a resident with a cardiac pacemaker after a pacemaker monitoring system was introduced, as required by facility policy. The resident was admitted with diagnoses including heart failure, hypertension, and the presence of a cardiac pacemaker. The existing care plan, initiated on 8/26/2025, addressed altered cardiovascular status related to pacemaker placement and included monitoring, documenting, and reporting chest pain or pressure. The resident’s H&P and MDS documented that the resident was cognitively intact, able to make decisions, and able to understand and be understood, with some need for assistance in activities of daily living. On 11/25/2025, progress notes documented that a family member brought in a heart monitor for the resident and instructed staff to plug it in and place it close to the resident. Despite this new intervention, there was no corresponding update to the resident’s care plan to include the use of the pacemaker monitoring system. During interviews, the ADON and RN acknowledged that the care plan had not been updated to reflect the pacemaker monitoring system and stated it should have been revised because it was important information regarding the resident’s heart. The DON also stated that care plans should be updated because they serve as a guide for staff to ensure appropriate interventions are in place. Review of the facility’s “Pacemaker - Management” policy indicated that pacemaker care was to be incorporated into the resident’s care plan, including specific interventions, monitoring frequency, and safety precautions, and the “Completion & Correction” policy required complete and accurate medical records with prompt, descriptive, and accurate entries.
Failure to Obtain Orders and Document Pacemaker Monitoring Device Use
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders and instructions for a newly implemented pacemaker monitoring device (PMD) and to ensure the resident’s cardiac pacemaker information was readily accessible in the medical record as required by facility policy. A resident with diagnoses including heart failure, hypertension, and the presence of a cardiac pacemaker was cognitively intact and able to make decisions. After returning from a cardiology appointment, the resident’s family member brought a heart monitor (PMD) to the facility and instructed a registered nurse to plug it in and place it near the resident for monitoring by the cardiologist. The nurse followed the family member’s instructions but did not contact the resident’s physician or cardiologist to obtain an order for the PMD or to receive instructions on its use. Interviews and record review confirmed there were no orders or instructions in the resident’s paper or electronic chart regarding the PMD, despite facility policy titled “Pacemaker – Management” requiring standardized guidelines for safe and effective care of residents with pacemakers. The DON stated that the nurse should have obtained orders and validated instructions such as acceptable distance for transmission, duration of use, charging procedures, and response to alarms. Additionally, review of the resident’s care plan for altered cardiovascular status related to pacemaker placement showed monitoring for chest pain or pressure, but there was no documentation that the PMD use and related pacemaker information were incorporated into the resident’s accessible medical record as indicated in the facility’s pacemaker management policy and lesson plan for licensed nurses.
Incomplete Documentation of Meal Intake Percentages
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident by not documenting required meal intake percentages over multiple dates. Specifically, the resident's nutrition records from early to late January showed repeated omissions, including missing documentation for breakfast, lunch, and dinner intake percentages on several days. This lack of documentation was identified during a review of the resident's records, which revealed a pattern of incomplete entries for meal intake. The resident involved had diagnoses of dementia and diabetes mellitus, with documented moderate cognitive impairment and required varying levels of assistance with eating and other activities of daily living. Interviews with facility staff, including a CNA and the DON, confirmed that meal intake percentages were required to be documented for each meal and that records were expected to be complete and accurate. The facility's policy also required nursing staff to document care provided, including ADL completion.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
The facility failed to maintain a safe and clean environment for a resident who was admitted with diagnoses including encephalopathy and chronic obstructive pulmonary disease, and who lacked the capacity to make decisions. During observations in the resident's room, surveyors noted raised round brown spots on the wall next to the wall-mounted television and brown smears on the seat of the recliner chair located next to the resident's bed. These findings were confirmed during interviews with both a CNA and the DON, who acknowledged the presence of the unclean conditions. A review of the facility's housekeeping policies indicated that all rooms should be kept clean and as free as possible of germs and other contaminating agents at all times, and that chairs should be damp wiped regularly, with all surfaces, including walls, thoroughly cleaned and disinfected after resident discharge. The observed conditions in the resident's room were not in accordance with these policies, resulting in the resident living in an unclean environment.
Failure to Obtain Timely Medication Admission Orders
Penalty
Summary
The facility failed to obtain medication admission orders for a newly admitted resident with multiple complex medical conditions, including metabolic encephalopathy, acute and chronic respiratory failure, type 2 diabetes mellitus with hyperglycemia, and seizures. Upon admission, the resident did not have discharge medication orders from the transferring hospital. The registered nurse (RN) notified the attending physician via text message on the day of admission to request medication orders, but the physician did not respond. The RN did not escalate the issue to the Medical Director as required by facility policy. As a result, the resident's medications were not ordered until the following day, delaying the administration of necessary treatments such as amiodarone, insulin lispro, ipratropium-albuterol, Keppra, olanzapine, and pantoprazole sodium. Interviews with facility staff confirmed that the lack of timely physician response and failure to follow up with the Medical Director led to the delay in obtaining and administering the resident's medications. Facility policy requires the attending physician to provide medication orders upon admission, which was not followed in this instance.
Failure to Order Therapeutic Diet for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a therapeutic diet, specifically a diabetic diet, was ordered for a resident with type 2 diabetes mellitus and hyperglycemia. Upon admission, the resident had discharge instructions from a general acute care hospital indicating the need for a diabetic diet. However, a registered nurse mistakenly ordered a regular standard portion diet instead of the required diabetic diet. This error was identified during a review of the resident's records, which showed that the incorrect diet order was active, and was confirmed by the nurse during an interview. The resident's medical history included metabolic encephalopathy, acute and chronic respiratory failure, type 2 diabetes mellitus with hyperglycemia, and seizures. Both the registered nurse and the Director of Nursing acknowledged the importance of providing the correct diet to address the resident's medical needs. The facility's policy required that therapeutic diets be ordered by a physician and provided in consultation with a dietitian, but this protocol was not followed in this instance.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These deficiencies were observed through direct surveyor findings, indicating lapses in the standard of care required for residents' bowel and bladder management, catheter maintenance, and infection prevention.
Milk Left at Room Temperature Beyond Safe Timeframe
Penalty
Summary
The facility failed to ensure that milk was not left at room temperature for more than two hours for three residents. Observations revealed that cartons of milk were left on the tables of three residents after being delivered with their lunch trays, and the residents indicated they would consume the milk later. The Dietary Services Supervisor confirmed that residents were encouraged to finish the milk before two hours elapsed, but the milk was observed to be left out beyond the recommended time frame. The facility's policy required dairy items to be kept under refrigeration until use and stored below 41 degrees Fahrenheit. The residents involved had various medical conditions, including generalized muscle weakness, hypothyroidism, dysphagia, dementia, and type 2 diabetes mellitus. Their assessments indicated moderate cognitive deficits and varying levels of assistance required with eating and bed mobility. The Dietary Services Supervisor acknowledged that milk should be consumed or disposed of within two hours of leaving the kitchen to prevent bacterial growth, as per facility policy and food safety standards.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Kitchen Refrigerator in Safe Operating Condition
Penalty
Summary
A deficiency was identified when a 3-door reach-in commercial refrigerator (Refrigerator 1) in the facility's kitchen was observed to have water dripping from its condenser fans onto food items stored below. On multiple occasions, surveyors observed water dripping onto pitchers of juice, water, and salad bowls that were prepared for residents. The Dietary Services Supervisor (DSS) confirmed during interviews that water should not be dripping from the condenser fans onto food and acknowledged that this could potentially cause food contamination. Further interviews with the Assistant Maintenance Director (AMD) revealed that Refrigerator 1 was not functioning properly and required repair. The facility's policy and procedure for maintenance services indicated that the maintenance department is responsible for ensuring all equipment is maintained in a safe and operable manner at all times. The failure to maintain the refrigerator in a safe operating condition resulted in the potential for food contamination.
Failure to Honor Resident's Beverage Preference
Penalty
Summary
A resident with dementia and severe cognitive deficits, who required supervision or assistance with eating and bed mobility, was observed repeatedly requesting milk while in their room. The resident pointed to the bedside table, which lacked both milk and a water pitcher. Despite the resident's repeated verbal requests, the Certified Nursing Assistant (CNA) present did not provide milk, nor did they seek assistance from other staff or leave the room to obtain milk. The CNA stated that the resident had already received milk, juice, and water during breakfast and noted that water was not at the bedside due to the resident's need for thickened liquids. The CNA acknowledged that the resident was likely asking for milk because they were thirsty or wanted milk. Review of the resident's records confirmed their cognitive and physical limitations, and the facility's policy indicated that residents should be offered meals and snacks according to their individual preferences. The failure to provide milk upon request, in accordance with the resident's expressed preference and the facility's policy, constituted a deficiency in honoring the resident's right to a dignified existence, self-determination, and communication.
Failure to Complete PASARR Level II Screening for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to complete a required PASARR Level II screening for a resident with serious mental illness (SMI). The resident was admitted with diagnoses including depression, schizoaffective disorder, and schizophrenia. A PASARR Level I screening indicated a positive result for SMI, and the Minimum Data Set (MDS) assessment showed the resident had intact cognitive skills for daily decision making. Following the Level I screening, the California Department of Health Care Services (DHCS) sent a notification letter to the facility indicating that a Level II mental health evaluation was required to determine the need for specialized services. However, the facility did not respond to the DHCS notification letter or to two or more separate attempts by DHCS to communicate within 48 hours of the Level I screening. As a result of the facility's lack of response, the required PASARR Level II screening for SMI was not scheduled in a timely manner. Interviews with facility staff confirmed that the notification letter was received but not acted upon, and that the facility's policy required daily checks of the PASARR portal and follow-up on Level II determinations. The failure to respond and complete the Level II screening meant the resident did not receive a timely evaluation for specialized services related to their mental health condition.
Failure to Implement and Document Comprehensive Care Plans for Pain and Bleeding Risk
Penalty
Summary
The facility failed to implement care plan interventions and adequately monitor and record pain characteristics for a resident with chronic pain. The resident, who had multiple diagnoses including COPD, acute respiratory failure, dysphagia, Parkinson's disease, and polyneuropathy, was care planned for chronic pain with specific interventions to monitor and document pain characteristics every shift and as needed. Despite this, documentation was missing regarding the location of pain when narcotic pain medication was administered on several occasions. The resident reported knee pain and, during observation, complained of severe pain in the left hip, thigh, and knee, with limited movement in the left lower extremities. The facility's policy required comprehensive, person-centered care planning, but these interventions were not consistently implemented or documented. Additionally, the facility failed to develop and implement a comprehensive, person-centered care plan for another resident who was receiving anticoagulant therapy and was at risk for bleeding. This resident had a history of tracheostomy, atrial fibrillation, and sepsis, and was cognitively impaired, unable to make decisions. The resident was prescribed both Amiodarone and Eliquis, which have a known drug interaction that increases the risk of bleeding. Despite a documented episode of blood in the urine and vomiting, and a pharmacist's review noting the increased risk, there was no care plan created to address the risk of bleeding within the required timeframe after the medications were ordered or after the change in condition. Interviews with nursing staff confirmed that care plans should have been created and implemented for both pain management and risk of bleeding, in accordance with facility policy. The lack of timely and comprehensive care planning and documentation resulted in unmet individualized needs for both residents, as identified through observation, interview, and record review.
Failure to Monitor Anticoagulant Therapy and Delay in Infectious Disease Consult
Penalty
Summary
The facility failed to provide appropriate care and services for two residents by not ensuring proper monitoring and follow-up as required by physician orders and care plans. For one resident with a history of atrial fibrillation, sepsis, and deep vein thrombosis, the care plan required monitoring for complications related to anticoagulant therapy, specifically for signs of bleeding. Despite documented episodes of blood in the urine and a known drug interaction between amiodarone and apixaban that increases bleeding risk, there was no evidence in the Medication Administration Record (MAR) that bleeding monitoring was performed or documented during the relevant period. Nursing staff confirmed that such monitoring should have occurred and was not documented. Another resident with recurrent urinary tract infections (UTIs), paraplegia, and anxiety disorder had a physician's order for an infectious disease consult due to a diagnosis of a multi-drug resistant organism (MDRO) in the urine and ongoing UTIs. Although the infectious disease doctor was notified of the need for a consult, there was a delay of over a week before the facility followed up on the appointment. During this time, the resident did not receive antibiotics for the current UTI and experienced bladder spasms, pain, and anxiety about the infection worsening. Nursing staff and the Director of Nursing acknowledged the delay in follow-up for the infectious disease consult. Both cases demonstrate a failure to provide care and services in accordance with physician orders, care plans, and resident needs. The facility's own policy requires that residents receive necessary care and services to attain or maintain their highest practicable well-being, but this was not achieved for these two residents due to lapses in monitoring and timely follow-up.
Failure to Timely Replace Missing Glasses and Communicate with Resident
Penalty
Summary
The facility failed to follow up in a timely manner with optometry to replace a missing pair of glasses for a resident with multiple diagnoses, including hemiplegia and polyneuropathy. The resident, who had moderate cognitive impairment and required assistance with personal hygiene, reported the loss of glasses to the Social Services Assistant (SSA) on 7/3/2025. The SSA made an initial call to the optometrist's office, where they were informed that optometry would notify the facility of their next visit. No further follow-up calls were made by the SSA after the initial contact, and the resident was not provided with any updates regarding the status of the replacement glasses. The resident expressed frustration and a sense of being ignored due to the lack of communication and the delay in replacing the glasses, which were necessary for reading. The SSA acknowledged being aware of the resident's need for the glasses to read periodicals but did not pursue additional follow-up. The Director of Nursing (DON) also recognized that more could have been done to communicate progress to the resident. The facility's policy required timely corrective action upon completion of the investigation of lost property, but this was not implemented in this case.
Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for two residents. One resident, who had a history of falls, confusion, impaired gait and balance, and was assessed as high risk for falls, was observed with their bed in a high position despite care plans and physician orders specifying the bed should be kept in the lowest position. Multiple staff interviews confirmed that the bed should have been kept low to prevent falls, and facility documentation indicated this intervention was part of the fall prevention protocol. The resident had previously experienced an unwitnessed fall, and assessments consistently identified them as high risk for further falls. Another resident, with a history of major depressive disorder and previous falls, was allowed to keep cigarettes and a lighter in their possession, contrary to facility policy and care plan interventions. The resident was supposed to have smoking materials stored securely by staff or in a safety box, but the safety box was not provided, and the resident retained both cigarettes and a lighter in their room. Interviews and observations confirmed the resident kept these items, and staff acknowledged that this was not in line with facility safety protocols, especially given the presence of other residents on oxygen in nearby rooms. Facility policies required individualized plans for safe storage and supervision of smoking materials, and staff were aware of the risks associated with residents keeping lighters and cigarettes in their rooms. Despite this, there was no effective plan implemented to ensure the safe storage of these items for the resident, and staff did not consistently follow up to retrieve smoking materials after use. This failure to follow established protocols and care plans resulted in an environment with preventable accident hazards for both residents.
Failure to Respond Timely to Feeding Tube Alarm
Penalty
Summary
A deficiency occurred when staff failed to respond in a timely manner to a continuous alarm from a resident's gastrostomy tube (GT) pump. The resident, who had a history of chronic respiratory failure, tracheostomy, and required enteral feeding via GT, was observed with the GT pump alarming for nearly half an hour. The alarm indicated a 'Patient Tube Block,' and the resident, who was cognitively intact, expressed annoyance at the persistent beeping. The GT pump was loaded with Jevity 1.2 and water flush, and the feeding was in progress at the time of the incident. During the incident, a Licensed Vocational Nurse (LVN) acknowledged that the alarm should have been checked by another licensed nurse, as the LVN was on the other side of the unit. The LVN was unsure of the cause of the alarm but recognized the importance of addressing it to prevent tube blockage. A Registered Nurse Supervisor later confirmed that proper care and maintenance of tube feeding includes ensuring the tube is not kinked, as this could prevent the resident from receiving the ordered nutrition and could lead to tube clogging. The failure to respond promptly to the GT pump alarm constituted a lapse in providing appropriate care and services for the resident receiving enteral feeding.
Failure to Ensure Proper Placement of Tracheostomy Mask for Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy and chronic respiratory failure did not receive proper respiratory care as ordered by the physician. During an observation, the resident was found asleep in bed with the tracheostomy mask positioned on the side of the neck rather than directly over the stoma, and the trach tie was slightly loose. The oxygen was set at 2L/min, but the mask was not delivering oxygen as intended because it was not properly placed. The respiratory therapist confirmed that the mask should have been directly on the stoma to ensure proper oxygenation. Record review showed that the resident was dependent to partially dependent for activities of daily living and required ongoing respiratory treatments, including oxygen therapy and tracheostomy care. The physician's orders specified the use of a T-mask with humidification and titration of oxygen to maintain adequate saturation levels. The facility's policy required routine tracheostomy care to prevent airway obstruction and impaired ventilation. Staff interviews confirmed that proper placement of the trach mask is essential for effective oxygen delivery, and failure to do so could result in the resident not receiving the ordered therapy.
Failure to Conduct Timely and Documented CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that performance evaluations (PEs) were conducted every 12 months for one out of four certified nursing assistants (CNAs) reviewed. Specifically, a review of personnel files revealed that one CNA was overdue for a PE, with no evaluation documented for the required period. The most recent PE for this CNA was signed only by the evaluator and not by the CNA, and the CNA confirmed during an interview that he had not seen or signed the evaluation. Additionally, the CNA stated he did not receive a PE in the previous year, and the last PE he recalled receiving and signing was from over a year prior. During interviews, the Director of Staff Development (DSD) and the Administrator acknowledged the lack of a formal policy for staff performance evaluation review, although a staff competency validation policy was provided. The policy outlined the purpose of competency validation but did not specifically address the requirement for annual performance evaluations. The absence of timely and properly documented PEs for the CNA had the potential to compromise resident safety and well-being, as regular evaluations are necessary to ensure staff competency.
Failure to Act on Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's recommendations regarding a resident's medication regimen were acted upon and documented, as required by facility policy. Specifically, for one resident with a history of chronic ulcer, edema, and cellulitis, the pharmacist made recommendations on two separate occasions to address the administration of Tylenol (acetaminophen) for pain management. The recommendations noted that if a PRN (as needed) pain medication is ordered for any level of pain (mild, moderate, or severe), there must be PRN orders for all levels, or the PRN pain management is considered inadequate. Despite these recommendations, there was no evidence that the facility staff or prescriber acted upon or documented any changes or decisions regarding the pharmacist's suggestions in the resident's medical record for the period reviewed. Record reviews and staff interviews confirmed that the pharmacist's recommendations were not followed or documented in the progress notes, and the facility's protocol was cited as the reason for inaction. The resident's medication administration records for May, June, and July indicated ongoing orders for Tylenol for mild pain, but there was no documentation addressing pain management for other pain levels as recommended. The facility's policy required that pharmacist recommendations be acted upon and documented by staff or the prescriber, which did not occur in this instance.
Failure to Document Restorative Nursing Services as Required
Penalty
Summary
The facility failed to document Restorative Nursing Aide (RNA) services provided to a resident with quadriplegia and cerebral palsy, as required by the facility's policy and procedure. The resident was dependent on staff for personal hygiene and bathing and had orders for passive range of motion (PROM) exercises to both upper and lower extremities, as well as the application of hand rolls, to be performed five times a week or as tolerated. Review of the Documentation Survey Report indicated that RNA services were not documented as provided on one specific day, and there was no documentation explaining the missed service. During interviews, the RNA responsible could not recall the events of the day in question and acknowledged that documentation should have been completed if services were not provided. The RNA later stated that, according to handwritten notes, all services had been completed but were not entered into the facility's charting system. The Director of Nursing confirmed that RNA services should be documented accurately to reflect care provided. The facility's policy required daily documentation of treatments and at least weekly documentation of progress, response to treatment, and functional status for residents in the Restorative Nursing Program.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who had been admitted with diagnoses including difficulty in walking and lack of coordination, was found to have their call light device on the floor beside their bed, out of reach. The resident's assessment indicated intact cognitive skills but a high level of physical dependence, requiring assistance with toileting, bathing, dressing, and personal hygiene. During an observation, it was confirmed that the call light was not accessible to the resident. Interviews with both an LVN and the DON confirmed that the call light should have been within the resident's reach to allow them to call for help if needed. A review of the facility's policy and procedure on the call system also stated that the call alert device must be placed within the resident's reach. The failure to ensure the call light was accessible constituted a breach of facility policy and resulted in a deficiency.
Failure to Notify Physician of Repeated Blood Glucose Monitoring Refusals
Penalty
Summary
Facility staff failed to notify a resident's physician of multiple refusals to allow blood glucose (accu check) monitoring on four separate occasions. The resident, who had diagnoses including type 2 diabetes mellitus, Alzheimer's disease, and dementia, was admitted and readmitted with a care plan indicating a history of refusing treatment and instructions to notify the physician after three refusals. Despite documentation of refusals on the Medication Administration Record, staff did not inform the physician as required by both the care plan and facility policy. Interviews with nursing staff and the Quality Assurance Nurse confirmed that the physician was not notified of the resident's refusals to undergo accu checks on the specified dates. The facility's policy required timely physician notification of treatment refusals, especially when there could be serious consequences. The failure to notify the physician was verified through record review and staff interviews.
Failure to Notify Physician of Repeated Accu Check Refusals
Penalty
Summary
Facility staff failed to implement the comprehensive person-centered care plan for a resident with diagnoses including metabolic encephalopathy, Alzheimer's disease, and dementia. The care plan, initiated on 1/3/2024, specified that staff should notify the resident's physician if the resident continued to refuse accu checks after three attempts. Despite this directive, documentation showed that the resident refused accu checks on multiple occasions in May 2025, but staff did not notify the physician as required by the care plan. Record reviews and staff interviews confirmed that the resident, who was severely cognitively impaired and required moderate assistance with activities of daily living, had a history of refusing treatment, including accu checks and insulin. The Medication Administration Record indicated refusals on several dates, and both a Licensed Vocational Nurse and the Quality Assurance Nurse acknowledged that the physician was not notified of these refusals, contrary to the care plan and facility policy.
Resident Allowed Out on Pass Without Written Physician Order
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including spinal stenosis and difficulty walking, was allowed to leave the facility on an overnight pass without a written physician's order. The resident was assessed as self-responsible with intact cognition but required partial to moderate assistance with several activities of daily living, including mobility and hygiene. Review of the resident's records showed no documented physician's order for the overnight pass, and the facility's policy required such an order to be written and documented by a licensed nurse. The nurse responsible for the resident's care stated that a telephone order was obtained but admitted to not documenting it due to being in a hurry. The attending physician later stated he would not have given such an order and could not recall if he had done so. Upon returning to the facility, the resident was found with abrasions and bruises on both arms and legs, as well as bleeding on the back of the head, and appeared intoxicated. The resident was subsequently sent to a hospital and diagnosed with alcohol intoxication and a closed head injury. Facility policy required that out-on-pass orders be documented and specify if the resident needed to be accompanied, but this was not followed in this instance, leading to the deficiency.
Failure to Provide Physician-Ordered Wound Care for Pressure Injury
Penalty
Summary
The facility failed to provide wound care treatment as ordered by the physician for one resident with a pressure injury related to a medical device. The resident, who had chronic kidney disease, a urinary tract infection, and a pressure ulcer, was admitted with an indwelling Foley catheter. Physician orders required daily wound care for an open wound on the penis, including cleansing with normal saline, applying hydro gel, and covering with a dry dressing. During observation, it was found that the wound was not covered with a dressing as ordered, and both the Licensed Vocational Nurse and Treatment Nurse confirmed that the wound should have been covered at all times according to the physician's orders. Further interviews revealed that the Certified Nursing Assistant assigned to the resident had changed the resident's diaper earlier in the day and also noted that there was no bandage over the open sore at that time. The facility's policy required treatments to pressure injuries and other skin integrity problems to be provided as ordered by the physician. The failure to keep the wound covered as ordered constituted a deficiency in following physician orders for wound care treatment.
Failure to Document Physician's Order for Resident Out on Pass
Penalty
Summary
The facility failed to ensure that the clinical record for one resident was complete and accurate when there was no written physician's order for an overnight out on pass before the resident left the facility. The resident, who had diagnoses including spinal stenosis and difficulty walking, was assessed as self-responsible with intact cognition but required partial to moderate assistance with several activities of daily living. Despite these needs, the resident left the facility for an overnight pass with a family member without a documented physician's order authorizing the absence. Upon review, there was no active physician's order for the overnight pass in the resident's medical record. Progress notes indicated that a nurse claimed to have obtained a verbal order from the physician but failed to document or carry out the order due to being in a hurry. The physician later stated he would not have given such an order and could not recall if he had authorized the pass. Facility policy required that a physician's order be documented for any out on pass, and that telephone orders be recorded with date, time, and signature at the time the order is taken. The resident returned to the facility with multiple injuries, including abrasions, bruises, and bleeding on the back of the head, and was noted to be intoxicated. The resident was subsequently sent to a hospital and diagnosed with alcohol intoxication and a closed head injury. The lack of a documented physician's order and assessment prior to the resident's absence resulted in an incomplete and inaccurate clinical record.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in significant injuries. On the morning of 3/31/2025, a resident with severe cognitive impairment and a history of dementia and bipolar disorder physically assaulted two other residents. The first incident occurred when one resident, who was sitting in a wheelchair and swinging a doll, had the doll make contact with the aggressor. In response, the aggressor struck the resident multiple times in the face with a closed fist, causing facial contusions, swelling, discoloration, bleeding from the mouth, and a closed head injury. The injured resident reported moderate pain and was subsequently transferred to an acute care hospital for further evaluation and treatment. Shortly after the first incident, the same aggressor approached another resident standing near the nurse's station. The aggressor pulled the resident's shirt and necklace from behind, breaking the necklace, and held the resident around the neck, resulting in redness on the left side of the neck. Both victims had severe cognitive impairment and diagnoses including dementia and other mental health conditions, making them particularly vulnerable to abuse. Staff interviews and documentation confirmed that the aggressor's actions were willful and met the facility's definition of abuse. The facility's policies required the provision of a safe environment and the prevention of abuse, but these were not effectively implemented, as evidenced by the occurrence of resident-to-resident altercations resulting in physical harm.
Delayed Call Light Response for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights for four sampled residents were answered promptly, as required by their care plans and facility policy. Resident 1, who was dependent on staff for bathing and toileting and at risk for falls, reported waiting an hour for assistance after pressing the call light to get help for a confused roommate. When no staff responded, Resident 1 attempted to transfer independently to a wheelchair to seek help and subsequently fell. Resident 1's care plan specifically required that call lights be within reach and that staff respond promptly to all requests for assistance. Other residents also reported significant delays in staff response to call lights. One resident stated that during the night shift, it could take 15-30 minutes for staff to respond after midnight. Another resident reported waiting up to an hour for assistance, which exacerbated their anxiety and breathing difficulties. These accounts were corroborated by the facility's Resident Council Minutes, which documented general complaints about long response times to call lights, particularly during the overnight shift. Record reviews showed that the affected residents had various medical conditions, including acute kidney failure, diabetes, history of falls, hypertension, muscle weakness, congestive heart failure, COPD, insomnia, dementia, and hemiplegia. The facility's policy required prompt and courteous responses to call lights, but interviews and documentation indicated that this standard was not consistently met, resulting in unmet needs for residents who required substantial or total assistance with activities of daily living.
Failure to Provide Adequate Supervision and Timely Response to Call Lights
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for multiple residents, resulting in preventable incidents. One resident, with a history of falls and dependent on staff for bathing and toileting, pressed the call light for assistance for their confused roommate but waited an hour without response. The resident attempted to transfer themselves to a wheelchair to seek help and subsequently fell. The care plan for this resident specifically required that the call light be within reach and that staff respond promptly to requests for assistance. Resident council minutes also documented general complaints about delayed call light responses, particularly during the overnight shift. In a separate incident, a resident with severe cognitive impairment and a history of dementia, schizophrenia, and psychosis was physically assaulted by another resident after an altercation in the hallway. Shortly after, the same aggressive resident assaulted a third resident, also with severe cognitive impairment and dementia, by pulling their shirt and necklace and holding them around the neck, resulting in redness and the need for first aid. Staff interviews confirmed that after the initial altercation, the aggressive resident was not adequately supervised, allowing a second assault to occur within minutes. Facility policies required prompt and appropriate interventions for residents displaying combative behaviors, including one-on-one supervision if a resident's behavior became abusive or unmanageable. Staff interviews indicated that during resident-to-resident altercations, involved residents should be separated and closely supervised to prevent further incidents. However, these procedures were not followed, leading to repeated physical altercations and injuries.
Failure to Develop Care Plan After Resident-to-Resident Altercation Resulting in Head Injury
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident who sustained a possible head injury after being struck multiple times in the head by another resident during an altercation. The resident, who had diagnoses including dementia, schizophrenia, and psychosis, was known to have severely impaired cognition and used a wheelchair for mobility. Following the incident, the resident exhibited facial contusions and a closed head injury, as confirmed by an emergency department evaluation after being transferred for further assessment. Despite the significant change in the resident's condition and the facility's policy requiring care plan updates in response to new problems or changes in condition, there was no care plan addressing the head injury or the events leading to it. Both the Medical Records Supervisor and the Director of Nursing confirmed that the resident's chart lacked a care plan related to the incident, and the facility's policy emphasized the importance of timely, individualized care planning to address residents' health and safety needs.
Failure to Develop and Implement Fall Risk Care Plan
Penalty
Summary
The facility failed to ensure that a licensed nurse developed and implemented a care plan for a resident who was identified as high-risk for falls. The resident was admitted with diagnoses including lack of coordination and osteoarthritis, and a Fall Risk Assessment conducted at admission indicated a high risk for falls. Despite this assessment, no care plan was created to address the resident's fall risk, and the resident was not added to the facility's fall management program at the time of admission. The resident's Minimum Data Set showed severely impaired cognition and a high level of dependence for most activities of daily living, including mobility and transfers. Staff interviews revealed that both the CNA and RN assigned to the resident were unaware of the resident's high fall risk status prior to the incident, and no specific interventions or monitoring protocols were in place. The facility's policies required that a care plan be developed and interventions documented for residents identified as high-risk for falls, but this was not done for the resident in question. As a result of these omissions, the resident fell out of bed and sustained a left elbow skin tear. The incident occurred when the CNA on duty heard a noise and found the resident on the floor. Both the MDS nurse and DON acknowledged that the lack of a care plan and failure to include the resident in the fall management program meant that staff did not have guidance on appropriate interventions, which could have contributed to the fall and resulting injury.
Failure to Develop and Implement Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to provide care and services to prevent a fall for a resident who was determined to be at high risk for falls. After admission, the resident was assessed using a Fall Risk Assessment (FRA) and scored as high risk, but licensed nurses did not develop or implement a care plan with interventions to address this risk. Additionally, the resident was not included in the facility's fall management program at the time the high-risk status was identified, contrary to the facility's policy and procedure. The resident had significant medical conditions, including lack of coordination and osteoarthritis, and was dependent on staff for most activities of daily living, with severely impaired cognition. Despite these factors and the high fall risk identified on admission, there was no care plan in place to guide staff on necessary interventions. Staff interviews confirmed that without a care plan, they were unaware of the resident's fall risk status and did not know what specific actions to take to prevent falls. As a result of these omissions, the resident fell out of bed and sustained a skin tear to the left elbow. The fall occurred when a CNA, unaware of the resident's high fall risk, found the resident on the floor after hearing a noise and a call for help. The Director of Nursing and other staff acknowledged that the lack of a care plan and failure to include the resident in the fall management program contributed to the incident.
Inaccurate Fall Risk Assessment Documentation After Resident Fall
Penalty
Summary
The facility failed to ensure accurate documentation on the Fall Risk Assessment (FRA) for one resident following a fall, as required by its policy and procedure for completion and correction of medical records. After the resident, who had diagnoses including lack of coordination and osteoarthritis, was admitted, the initial FRA indicated a high risk for falls. The resident was noted to have severely impaired cognition and required extensive assistance with most activities of daily living, including transfers and mobility. On the date of the incident, the resident experienced a fall from bed and sustained a skin tear. Despite this event, the subsequent FRA completed by a registered nurse did not document the recent fall and incorrectly indicated that the resident was not at high risk for falls. The FRA score was recorded as lower than the initial assessment, and the fall within the past three months was not acknowledged in the documentation. Interviews with facility staff, including the MDS nurse, the registered nurse who completed the assessment, and the Director of Nursing, confirmed that the FRA should have reflected the recent fall, which would have maintained the resident's high-risk status. The inaccurate documentation resulted in a discrepancy in the resident's care assessment and did not prompt the creation of an updated care plan for fall risk, as required by facility policy.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to promptly respond to call lights for three residents, which is a violation of the facility's policy and procedure on communication and call systems. Resident 7, who was admitted with diagnoses including a urinary tract infection, type 2 diabetes mellitus, and difficulty in walking, required moderate assistance for daily activities. Despite having a care plan that encouraged the use of a bell to call for assistance, Resident 7 reported waiting up to an hour for help with changing soiled diapers, leading to feelings of neglect. Resident 11, diagnosed with quadriplegia and anxiety disorder, was dependent on staff for all activities of daily living. This resident reported having to yell for assistance or call a family member to contact the facility due to unresponsive staff, particularly during the night and morning shifts. Resident 12, with functional quadriplegia and chronic respiratory failure, also depended on staff for all daily activities. This resident reported waiting over half an hour for assistance during the night shift. Interviews with the Director of Nursing confirmed that staff should answer call lights immediately to prevent incidents and maintain resident dignity. The facility's Resident Council Minutes also documented complaints about delayed responses to call lights. The facility's policy, revised in 2012, mandates that nursing staff answer call bells promptly and courteously, which was not adhered to in these cases.
Deficiency in Meal Presentation and Palatability
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable and attractive, as per their Dietary Department Policy and Procedure. This deficiency was observed in two residents. Resident 7, who was admitted with conditions including a urinary tract infection, type 2 diabetes mellitus, and difficulty in walking, reported that the food was sometimes not good, specifically mentioning that the green beans were mushy and lacked flavor. During an observation, the lunch tray for Resident 7 included turkey with cream sauce, green beans, and roasted red potatoes, all sitting in a puddle of liquid, which the Dietary Manager confirmed did not look appetizing. Similarly, Resident 9, who had diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, and type 2 diabetes mellitus, also reported that the food was not appealing. The lunch tray for Resident 9 contained a piece of turkey and a ball of rice, which the resident felt needed more color and suggested that the rice would look better if spread out rather than in a ball shape. The facility's policy emphasizes the preparation of nutritionally adequate and attractive meals, which was not adhered to in these instances.
Failure to Serve Meals According to Menu
Penalty
Summary
The facility failed to serve meals according to the menu on 3/9/2025, as evidenced by the experience of one resident. The resident, who was admitted to the facility with conditions including atrial fibrillation, COPD, and type 2 diabetes mellitus, reported not receiving the meal listed on the facility's menu. Instead of the planned meal of ham with raisin sauce, au gratin potatoes, roasted asparagus, wheat roll, and carrot cake, the resident was served a corn dog, rice, and a flour tortilla. This discrepancy was confirmed during an interview and record review with the resident. The facility's policy and procedure titled 'Menu' requires that meals meet the nutritional needs of residents and adhere to the guidelines set by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. The resident indicated that deviations from the menu occurred about twice a week, suggesting a pattern of non-compliance with the facility's own policies. This failure had the potential to impact the resident's nutritional intake, particularly given their medical conditions.
Failure to Timely Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure timely notification to the Ombudsman regarding a facility-initiated discharge for a resident. The resident, who was admitted with conditions including aphasia, hemiplegia, and hemiparesis following a cerebral infarction, was discharged on 12/23/24. The Notice of Proposed Transfer and Discharge (NPTD) was signed by the resident's representative on the same day as the discharge, but the Ombudsman did not receive the NPTD until 12/31/24, after the discharge had already occurred. Interviews and record reviews revealed that the facility's Social Services Director stated that the NPTD is typically sent to the Ombudsman within 30 days after discharge, but could not recall who sent the NPTD for this particular resident. The facility's policy requires that the NPTD be provided to the resident, responsible party, and Ombudsman prior to the transfer or discharge. This oversight had the potential to leave the resident unprotected from an inappropriate discharge.
Incomplete Documentation of Medical Emergencies
Penalty
Summary
The facility failed to ensure the clinical records for two residents were complete and accurate. For the first resident, a Licensed Vocational Nurse (LVN) did not accurately document the resident's condition in the Change in Condition Evaluation (CIC). The CIC indicated the resident was unresponsive, without a pulse, and not breathing, but it did not include the names of staff who responded to the rapid response or those who provided CPR. Additionally, the CIC failed to note that the resident was bleeding from both nostrils. Interviews revealed discrepancies in the documentation, with the LVN stating the resident had weak and shallow breathing and a pulse, contrary to the CIC's indication of no pulse. For the second resident, the clinical record was also incomplete. The CIC did not document the names of staff who responded to the rapid response, the time the Rapid Response Team (RRT) arrived, or the names of staff who provided CPR. Furthermore, the name of the staff member who attempted to start an intravenous catheter was missing. The Registered Nurse Supervisor (RNS) confirmed the lack of documentation and emphasized the importance of accurate records to demonstrate the care provided. The facility's policies and procedures require thorough documentation of medical emergencies, including the condition of the resident at the time of discovery, the initiation of CPR, and the response of nursing staff. However, these requirements were not met in the cases of the two residents, leading to incomplete records that could hinder the evaluation of care and staff performance.
Failure to Administer Flu Vaccines Leads to Resident Hospitalizations
Penalty
Summary
The facility failed to prevent and control the spread of influenza among its residents during the current flu season. Specifically, the facility did not ensure that Infection Preventionists (IPs) provided necessary information and education regarding the flu vaccine to residents or their responsible parties. This resulted in several residents not being offered the flu vaccine, and one resident who consented to the vaccine did not receive it. Consequently, multiple residents were diagnosed with the flu, and some were hospitalized with severe complications such as sepsis and pneumonia. The report highlights that the facility lacked a system to track the flu vaccination status of residents. This deficiency affected seven residents, who either were not offered the vaccine or did not receive it despite consenting. The absence of a tracking system contributed to the facility's inability to ensure that residents were vaccinated in a timely manner, increasing their risk of contracting the flu and experiencing severe health complications. The residents involved had various medical conditions that increased their vulnerability to flu complications, such as immunodeficiency, diabetes, and dementia. The report details the medical history and conditions of each resident, noting that several had impaired cognition and were unable to make medical decisions independently. The failure to offer and administer the flu vaccine as per the facility's policy and procedure led to significant health issues for these residents, including hospitalizations for severe respiratory symptoms and infections.
Removal Plan
- IP 1 and IP 2 were immediately placed on administrative suspension, pending investigation.
- The ADM promoted a Licensed Vocational Nurse (LVN) to be the interim IP (IP 3). IP 3 had received the Infection Prevention Training for Skilled Nursing Facilities, as well as worked as an Infection Prevention & Control Nurse at another facility. The DON will be responsible for the oversight of the Infection Prevention & Control Program for compliance by conducting weekly compliance audits and verification.
- The following actions were immediately completed for Residents 1, 2, 3, 4, 5, and 6 related to influenza vaccine offering and administration: Resident 1: The influenza vaccine was offered to Resident 1's RP (RP 1) who consented to receive the flu vaccine. Resident 1 received the flu vaccine. Resident 2: The DON contacted Resident 2's PR (RP 2) to verify Resident 2's influenza vaccination status and left a voice message. The ADON called RP 2 and received a declination for the seasonal Influenza vaccine. Resident 3: The influenza vaccine was consented by Resident 3's representative the interdisciplinary team (IDT) Resident 3 received the flu vaccine. Resident 4: The influenza vaccine was offered to Resident 4, who consented to receive the flu vaccine. Resident 4 received the flu vaccine. Resident 5: The influenza vaccine was consented by the RP 5 (IDT) as the resident's representative. Resident 5 physically did not allow the nurses to administer the seasonal Influenza vaccine. Resident 5's attending physician was notified. Resident 6: The influenza vaccine was offered to Resident 6's RP (RP 6) who consented to receive the flu vaccine. Resident 6 received the flu vaccine.
- Resident 7 remained hospitalized.
- The ADM, the DON, and the Medical Director conducted a Quality Assurance Performance and Improvement (QAPI) meeting to discuss Infection Prevention and Control concerns related to influenza vaccination including screening, offering, tracking, and monitoring of influenza vaccine status.
- The DON, and ADON conducted an audit of current residents and revalidated the consents for influenza immunizations. The DON and ADON initiated verification of influenza vaccine declinations.
- The ADM and DON initiated an in-service education to the licensed nurses (all licensed nurses) regarding the P&Ps for Influenza Prevention and Control.
- The ADM contacted the Pharmacy Representative to reserve 50 doses of the seasonal Influenza vaccine, which was delivered.
Failure to Document Flu Vaccine Consent Leads to Outbreak
Penalty
Summary
The facility failed to ensure accurate documentation on the Consent/Declination Influenza Immunization (CDII) forms for seven residents, as per the facility's policy and procedure. The Infection Preventionist (IP) did not speak to the residents' responsible parties (RPs) but documented that the RPs declined the flu vaccine for the residents. This documentation was done without actual communication, as the IP only left voicemails and did not receive verbal declinations. The IP admitted to falsifying records due to stress and the need to expedite the process for an upcoming vaccine clinic. The lack of accurate documentation and communication resulted in the residents not being offered the flu vaccine for the current flu season. Consequently, a flu outbreak occurred, with three residents being diagnosed with the flu and subsequently hospitalized due to severe complications such as sepsis and pneumonia. The facility's failure to track and document the residents' flu vaccination status contributed to the outbreak and placed other residents at risk of developing flu-related complications. The facility's policies required that two licensed nurses be present during the conversation with a RP to validate consent or declination. However, this procedure was not followed, and the documentation was falsified. The Director of Nursing (DON) confirmed that the process was not adhered to and acknowledged that the falsification of medical records was a patient safety issue. The facility also lacked an organized system to track residents' flu vaccination status, further exacerbating the situation.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding hand hygiene and Enhanced Barrier Precautions (EBP). Two certified nurse assistants (CNAs) did not wear the required personal protective equipment (PPE) or perform hand hygiene when entering the rooms of residents who were on EBP. These residents, identified as having chronic respiratory failure and requiring tracheostomy and ventilator support, were at increased risk for infection due to their medical conditions. During observations, CNA 2 entered Resident 14's room without performing hand hygiene or donning a gown and gloves, despite the presence of a sign indicating the need for EBP. CNA 2 engaged in patient care activities such as adjusting the resident's bedding and tracheostomy tubing without the appropriate PPE. Similarly, CNA 4 entered Resident 13's room without performing hand hygiene or wearing gloves, even though they acknowledged the requirement to do so before providing care. Interviews with the Infection Preventionist and the Director of Nursing confirmed that staff were expected to follow EBP protocols to protect residents from multidrug-resistant organisms (MDROs). The facility's policies emphasized the importance of hand hygiene and PPE use to prevent the spread of infections. However, the observed actions of CNAs 2 and 4 demonstrated a failure to comply with these protocols, potentially putting residents at risk for infection.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to adhere to standard infection prevention and control practices, as evidenced by multiple staff members not wearing appropriate personal protective equipment (PPE) when entering residents' rooms or providing care to residents on transmission-based precautions for COVID-19. Specifically, six staff members, including CNAs and an LVN, did not wear face shields, gowns, or gloves as required by the facility's policies and procedures. This was observed in several instances, such as when CNAs were in the room of a resident on quarantine without face shields, despite the presence of signs indicating the need for such precautions. Additionally, the facility did not ensure that residents who tested positive for COVID-19 wore masks when outside their rooms. Four residents were observed in a hallway designated as a red zone for COVID-19 positive residents, without masks, and staff did not encourage or provide masks to these residents. This lack of adherence to mask-wearing protocols contributed to the spread of infection within the facility. Furthermore, staff members failed to perform hand hygiene before and after providing care to COVID-19 positive residents and when entering or exiting rooms. This was observed with CNAs and an LVN who did not perform hand hygiene or wear the appropriate PPE, increasing the risk of transmitting infectious agents. The facility's policies clearly outlined the importance of hand hygiene and PPE use, yet these protocols were not followed, leading to widespread infection among residents and staff.
Failure to Develop Comprehensive Care Plan for Elopement Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident identified as being at risk for elopement. Despite the resident's cognitive skills being intact and no wandering behavior being observed, the resident expressed a desire to go home, which was interpreted by staff as a risk for elopement. The facility's policies required a care plan to address such risks, but no care plan was found in the resident's medical record to address this concern. The resident was initially moved to a locked unit, Area 4, which was designated for residents with serious mental health conditions and those at risk of elopement. However, the resident did not have any of the mental health diagnoses typical of Area 4 residents, such as schizophrenia or dementia. The move was made after the resident verbalized wanting to go home, but there was no documented evidence of elopement behavior. The resident's responsible party agreed to the move initially but later complained, leading to the resident being moved back to a different area. Interviews with staff revealed inconsistencies in the assessment of the resident's risk for elopement. Some staff members had not observed any elopement behavior, while others believed the resident was at risk due to verbal expressions of wanting to leave. The Director of Nursing confirmed that a care plan addressing the risk for elopement should have been in place but was not found in the resident's records. The facility's policies required that care plans be updated to reflect any changes in a resident's condition, which was not done in this case.
Failure to Provide Padded Side Rails for Resident with Seizures
Penalty
Summary
The facility failed to ensure the safety of a resident with a history of seizures by not providing padded side rails on the resident's bed. The resident, who was admitted with diagnoses including Alzheimer's Disease and seizures, was observed without padded side rails despite having a physician's order for seizure medication and a history of tremors. The resident's Minimum Data Set indicated severe cognitive impairment and a need for assistance with daily activities, highlighting the importance of safety measures such as padded side rails. On the day of observation, the resident was initially found with unpadded side rails and was later provided with padded side rails after being observed with tremors. Interviews with facility staff, including the Assistant Director of Nursing and the Administrator, revealed that the resident had received a new bed with side rails from a hospice agency, and the facility had not immediately padded the side rails. The Director of Nursing stated that residents with a history of seizures should have interventions like padded side rails to prevent injury, as outlined in the facility's policy on seizure precautions.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 48 and Resident 109, had their call lights within reach, which could potentially result in them not receiving timely care and services. Resident 48, who was admitted with diagnoses including transient cerebral ischemic attack, hemiplegia, anxiety, and bipolar disorder, had a moderately impaired cognition and fluctuating decision-making ability. During an observation, it was noted that Resident 48's call light was clipped to the wall and not within reach, as confirmed by both the resident and Registered Nurse 2. The Director of Nursing acknowledged that the call light should always be within reach as per facility policy. Similarly, Resident 109, who was readmitted with diagnoses including cerebral infarction, COPD, and heart failure, had severe cognitive impairment and required substantial assistance with daily activities. During an observation, Resident 109's call light was found on the floor, out of reach, which was confirmed by both the resident and Certified Nurse Assistant 7. The facility's policy and procedure indicated that call cords should be placed within the resident's reach, and Resident 109's care plan specifically noted the importance of keeping the call light accessible due to a high risk for injury or fracture.
Failure to Revise Care Plans for Weight Loss and Fall Risk
Penalty
Summary
The facility failed to revise comprehensive care plans for two residents, leading to potential unmet individualized needs. Resident 176's care plan was not updated following a significant weight loss, despite an increase in snacks from twice a day to three times a day as part of the nutritional regimen. The Registered Dietitian noted the resident's dementia affected hunger and satiety receptors, contributing to the weight loss. The Quality Assurance Nurse confirmed that the care plan was not updated to reflect the new dietary orders, which was necessary to ensure proper interventions and prevent further weight loss. Resident 36's care plan was not revised after a fall incident in the restroom, which resulted in a forehead laceration. The resident had a history of falls and muscle weakness, and the care plan indicated a risk for falls. However, no new interventions or approaches were added to the care plan following the incident. Both the Registered Nurse and Quality Assurance Nurse acknowledged that the care plan should have been updated to include additional interventions to prevent future falls. The facility's policies and procedures require that care plans be reviewed and revised after significant changes in a resident's condition, such as weight loss or falls. The failure to update the care plans for Residents 176 and 36 was contrary to these policies, potentially affecting their physical and psychosocial well-being.
Failure to Follow G-tube Medication Administration Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure for safe medication administration for a resident with a gastrostomy tube (G-tube). On the specified date, a Licensed Vocational Nurse (LVN) administered medications through a resident's G-tube without stopping to reassess the situation or notifying a supervisor or physician when the G-tube became clogged for over 30 minutes. This oversight occurred despite the facility's policy, which requires contacting a physician if the clog persists after initial attempts to clear it. The resident involved had been admitted with diagnoses including gastrostomy-related issues and was dependent on staff for daily activities due to moderate cognitive impairment. During the medication administration, the LVN observed that the G-tube was clogged with a milky substance and attempted to clear it by milking the tube for over 30 minutes. The LVN did not follow the facility's policy to seek assistance or notify a physician when the clog persisted, despite having experienced similar issues with the resident's G-tube the previous day. Interviews with the LVN and a Registered Nurse (RN) revealed that the LVN typically milked the G-tube until it cleared, without seeking help. The RN confirmed that the LVN should have sought assistance or contacted the physician when the clog did not resolve quickly. The facility's policy on enteral tube medication administration clearly states that persistent clogs should be reported to a physician if initial techniques fail, which was not followed in this instance.
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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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