Park View Nursing And Subacute
Inspection history, citations, penalties and survey trends for this long-term care facility in Reseda, California.
- Location
- 6740 Wilbur Ave Opco, Llc, Reseda, California 91335
- CMS Provider Number
- 555716
- Inspections on file
- 74
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Park View Nursing And Subacute during CMS and state inspections, most recent first.
A resident with DM, stroke, and HTN had an order for SQ insulin lispro per sliding scale before meals and at bedtime. Review of the MAR showed that a RN repeatedly documented insulin doses at times significantly later than the scheduled administration times. In interview, the RN stated insulin was given around mealtime as ordered but documentation on the MAR was completed late rather than immediately after administration. The DON and facility policy both indicated that licensed nurses must document medication administration directly after giving medications and that medication times must follow established timing guidelines.
A resident with a history of stroke, DM, and HTN, and intact cognition, had family concerns about care submitted by email to the ADM. Although the ADM acknowledged receipt, the concern was never entered on a grievance form, logged in the grievance binder, or investigated as required by the facility’s grievance P&P. The SSD and DON confirmed that no grievance was recorded for this resident, despite facility policy requiring staff to initiate a grievance/concern form and log upon receipt of any complaint. This failure violated the resident’s right to voice grievances and have the facility respond.
A resident admitted with stroke, DM, and HTN, who had intact cognition and required moderate assistance with ADLs, did not receive a written summary of the baseline care plan. ICC documentation showed the section indicating that a copy of the care plan was provided was left blank, and the CM and DON could not locate any record that a written baseline care plan summary had been given. Review of the facility’s baseline care plan policy confirmed requirements for timely development of a baseline care plan but did not clearly address providing a written summary to the resident or representative.
A resident with a sacrococcygeal stage III PI was admitted with orders and a care plan for use of a low air loss mattress (LALM) to support wound management, including monitoring for proper settings and functionality. During observation, the resident was found on the LALM with an incontinence brief, a flat sheet, and a cloth incontinence pad, creating four linen layers between the resident and the mattress, contrary to staff statements that only one to two layers should be used for the LALM to work properly. The DSD and DON confirmed that excess linen layers interfere with LALM function and acknowledged there was no specific facility P&P for LALM use, while the existing pressure ulcer protocol only generally referenced physician orders for pressure reduction surfaces.
Surveyors found that multiple residents with orders for low air loss mattresses (LALM) for PU/PI prevention and wound healing were using these specialty beds without any facility policy or procedure in place to guide their use. The DON confirmed there was no written P&P for LALM, including no direction on linen use, and that staff relied on manufacturer guidelines, which did not address linen. The administrator acknowledged that a P&P for LALM should exist to guide care for the many residents using these mattresses, despite job descriptions assigning responsibility for developing and implementing such policies.
A resident with severe cognitive impairment, functional quadriplegia, and multiple comorbidities was observed lying in bed with the call light placed on a bedside table out of reach, despite needing staff assistance for incontinence care and other ADLs. An LVN confirmed the call light was not within reach as required, and a CNA later stated he typically checks call light placement at the start of his shift but had forgotten to do so for this resident. The DON acknowledged that call lights must be within reach so residents can request assistance and that lack of access can lead to delayed care and negatively affect dignity. Facility policies on the call system and dignity require that residents have a means to call staff from bed and be cared for in a way that promotes self-worth and self-esteem.
A resident with traumatic brain injury, seizures, hydrocephalus, type 2 DM, and limited decision-making capacity had a physician order for bilateral AFOs to be applied to the lower extremities several times per week for specified hours with skin checks. During observation, the resident was found in bed with the right AFO rotated to the side and not providing proper support. The DOR confirmed the device was improperly applied, and the RNA who applied it stated he was unaware it was incorrect, while acknowledging it should remain correctly positioned. The DON stated staff should monitor AFO placement and skin condition. Facility policies required trained, competent staff to maintain and supervise assistive devices and to provide appropriate services and equipment to maintain or improve mobility, but the improper AFO application showed these requirements were not followed.
Three residents were placed at increased risk for injury when staff failed to ensure bed siderails were fully padded as ordered for two residents with seizure disorders, and did not provide a required floor mat, adequate lighting, or open curtains for a resident with impaired mobility. Nursing staff confirmed these safety measures were necessary, and facility policies required their implementation.
A licensed nurse failed to measure and document a resident's apical pulse before administering Flecainide, as required by a physician's order for a resident with atrial fibrillation. The nurse relied only on blood pressure and radial pulse checks, was unaware of the specific order, and did not follow established medication administration protocols, resulting in repeated administration of the medication without the necessary assessment.
The facility did not ensure timely replacement or proper documentation of emergency medication kits (E-kits) in two medication rooms after they were opened, and failed to notify the pharmacy as required by policy. A resident with sepsis and severe cognitive impairment was involved, and staff interviews confirmed lapses in following procedures for E-kit management and documentation.
A nurse failed to check a resident's apical pulse before administering Flecainide, as required by the physician's order for a resident with atrial fibrillation. The medication was given multiple times without the necessary pulse check, and the electronic medical record did not prompt for this parameter. The facility's policy and pharmacy recommendations to follow physician orders and monitor vital signs were not followed.
Seven residents on a puree diet were served a lemon crisp dessert that was too thick and did not meet IDDSI Level 4 standards, as confirmed by dietary staff during a test tray observation. The dessert failed the required spoon tilt test, indicating it was not prepared in the appropriate form for residents with dysphagia.
Surveyors found that kitchen staff failed to label and date stored bell peppers, did not check temperatures for several food items on the tray line, and a dietary aide touched his face and glasses with gloved hands without immediately washing hands or changing gloves. These actions were not in accordance with facility policies for food safety and staff hygiene.
A resident with a tracheostomy and ventilator dependence did not have an individualized care plan for oral care, resulting in observed dry, cracked lips and lack of staff intervention. Another resident, with multiple serious diagnoses, was found on the floor without a required floor mat in place, despite an active order and care plan intervention for fall prevention. Both deficiencies were confirmed through observation, staff interviews, and record review.
A resident with an enteral tube did not receive the full dose of crushed medications when an LVN left excess medication in the cups after administration and failed to flush the tube with the physician-ordered amount of water between medications. Both the LVN and DON confirmed that the full dose and proper flush volume were required by orders and facility policy.
A resident who was fully dependent on staff for all ADLs, including oral care, was found with severely dry, cracked lips and a thick layer of dried saliva and skin. The resident, who had multiple complex medical conditions and was on a ventilator and feeding tube, did not receive necessary oral hygiene, as confirmed by a nurse and facility policy review.
A resident with a history of neurogenic bladder and urinary retention, who was dependent on staff for care, was observed with a urinary catheter that had a long dependent loop, coils, and a kink, with visible sediment in the tubing. Staff and policy confirmed that catheter tubing should remain straight and unobstructed, but this was not maintained, contributing to improper catheter care and increased risk of UTI.
A resident with end stage renal disease and severe cognitive impairment did not have their post-dialysis weight documented by the dialysis center, and facility staff did not follow up as required by policy. This resulted in incomplete post-dialysis assessment documentation for the resident's hemodialysis care.
A deficiency was found when an LVN discovered an unlabeled, unpackaged tablet in a medication cart drawer. The LVN and DON both confirmed that all medications should be properly packaged and labeled to ensure correct administration and compliance with facility policy, which requires medications to be stored in legally compliant containers and contaminated medications to be removed immediately.
A resident with multiple diagnoses and unable to provide informed consent was incorrectly documented as having an Advance Directive in their medical record, despite confirmation from both the responsible party and facility staff that no such document existed. This resulted in inaccurate medical recordkeeping regarding the resident's Advance Directive status.
A facility failed to create a comprehensive care plan for a resident who preferred to keep food at their bedside. Despite the resident's diagnoses and preference, the care plan lacked specific interventions to address this, as confirmed by the DON. The facility's policy requires individualized care plans, but this was not implemented, potentially affecting the resident's quality of life and care.
A facility failed to complete a discharge summary for a resident who was readmitted with cervical disc degeneration and other conditions. Despite the resident having intact cognition, no discharge summary was documented upon their discharge, as confirmed by the Medical Records Director and DON. This oversight was against the facility's policy, which requires a discharge summary to be completed within 30 days of discharge.
A facility failed to document a resident's fluid intake, contrary to its hydration policy, placing the resident at risk for dehydration. The resident, with severe cognitive impairment and chronic conditions, required assistance with daily activities. Staff interviews revealed that CNAs did not document fluid intake in milliliters, and the Director of Nursing confirmed that intake was not documented unless ordered. This oversight could lead to dehydration and medical complications.
A facility failed to follow its policy on preventing foodborne illness by not discarding cooked eggs left on a resident's bedside table for over 24 hours. The resident, with COPD and functional quadriplegia, confirmed the eggs were not refrigerated. The Dietary Supervisor acknowledged the eggs should have been discarded after two hours, as per facility policy, to prevent bacterial growth.
A facility failed to implement its Enhanced Barrier Precautions and Hand Hygiene policies, leading to a deficiency in infection control. A CNA did not wear a gown while changing bed linen for a resident on EBP and did not perform hand hygiene after removing gloves. The resident had conditions including diabetes with a skin ulcer and cellulitis, requiring enhanced precautions. Staff interviews confirmed the failure to adhere to policies requiring gowns and gloves during high-contact activities and hand hygiene after removing PPE.
The facility failed to maintain room temperatures between 71-81°F, affecting a resident who reported discomfort due to cold conditions. Observations showed two rooms with temperatures below the required range, and the Maintenance Supervisor acknowledged the need for thermostat adjustments. The resident, with multiple health issues, used an extra blanket to stay warm, highlighting the deficiency in maintaining a homelike environment.
The facility failed to follow its policy on the safe placement of power strips, leading to potential hazards. During a tour, a power strip was found on the floor next to a resident's bed, and another was improperly secured to a bed rail with plastic gloves. Both residents involved had intact cognition. The facility's policy requires power strips to be stored safely to prevent tripping hazards.
A resident with a history of falls experienced an unwitnessed fall, and the facility failed to conduct the required neurological assessment as per its policy. Despite the protocol mandating a 72-hour post-fall assessment, it was not completed, and the assessment was not resumed after the resident returned from the hospital. The DON incorrectly believed a physician's order was needed to continue the assessment, leading to incomplete monitoring and documentation.
A resident with multiple health conditions experienced unrelieved pain due to the facility's failure to ensure timely physician notification for additional pain medication. The LVN faced technical difficulties contacting the on-call physician and did not escalate the issue, instead passing it to the next shift. The facility's pain management policy requires timely physician notification to maintain resident comfort.
The facility did not complete food preference assessments within 48 hours of admission for four residents, as required by policy. This delay, acknowledged by the Dietary Supervisor and Dietician, could lead to residents being served unwanted food, potentially decreasing meal intake and causing weight loss.
The facility failed to ensure call lights were within reach for three residents, potentially delaying care. A resident with dementia had the call light on the floor, another with spinal stenosis had it hanging off the bed, and a third dependent resident had it wrapped around side rails. Staff confirmed these observations, highlighting the importance of accessible call lights for timely assistance.
The facility failed to maintain current copies of advance directives for four residents, risking unwanted treatments. Despite having executed advance directives, the documents were missing from the medical records of residents with various medical conditions, including sepsis, multiple sclerosis, and dementia. The Social Service Director acknowledged the lack of follow-up with families to obtain these critical documents.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident receiving antibiotics for a UTI lacked a care plan for antibiotic use, risking delayed healing. Another resident's care plan did not reflect physician's orders for RNA exercises, risking functional decline. A third resident with urinary retention had no care plan, impacting care monitoring. These deficiencies highlight a failure to adhere to the facility's policy requiring timely development of care plans.
Three residents in an LTC facility were at increased risk of pressure ulcers due to incorrect settings on their low air loss (LAL) mattresses. The mattresses were not adjusted according to the residents' weights, leading to improper pressure distribution. Staff confirmed and corrected the settings, acknowledging the potential harm caused by the initial errors.
A facility failed to ensure that nurses attempted non-pharmacological interventions before administering prn opioid pain medication to a resident with acute respiratory failure, tracheostomy, and gastrostomy status. The resident, who had moderately impaired cognition and required maximum assistance, was prescribed hydrocodone-acetaminophen for severe pain. However, documentation showed that non-pharmacological interventions were not attempted on several occasions, contrary to the facility's pain management policy.
The facility failed to properly document and administer medications, including antibiotics and controlled drugs, for several residents. Discrepancies between the MAR and CDR were found, raising concerns about medication errors and potential drug diversion. The DON confirmed these issues, emphasizing the importance of proper procedures to prevent errors.
The facility failed to properly label insulin and eye drop medications, risking their effectiveness, and allowed unauthorized access to a medication room. Two residents had insulin without open dates, and another resident's eye drops were used past the expiration period. Additionally, a Dietary Supervisor accessed a medication room, contrary to policy.
The facility failed to maintain infection control practices for three residents, including allowing a nasal cannula to touch the floor, not labeling urinals, and not labeling an IV administration set. These actions increased the risk of infection due to potential contamination and cross-contamination.
A facility failed to cover a resident's urinary catheter collection bag with a dignity bag, compromising the resident's dignity. The resident, with intact cognition and decision-making capacity, was observed with a visible urine bag. The Infection Preventionist confirmed the absence of a dignity bag, which is required by the facility's policy to ensure resident privacy and dignity.
A facility failed to timely collect and follow up on a STAT fecal occult blood test for a resident with Guillain-Barre syndrome and myasthenia gravis. Despite a STAT order placed after the resident's family reported black stool, the specimen was not collected during a bowel movement, and the order was delayed. The resident's hemoglobin levels dropped significantly, and a positive FOBT was only noted days later, leading to an emergency hospital transfer. Interviews revealed the facility's policy required STAT orders to be completed within 4 to 6 hours, highlighting a failure to adhere to protocols.
The facility failed to honor the food preferences of two residents, violating their rights to self-determination. One resident, recovering from knee surgery and gastric bypass, was denied cereal for dinner, while another resident with acute kidney failure was denied hard-boiled eggs. Both requests were feasible, as confirmed by the Dietary Supervisor, but were not fulfilled by the staff member responsible.
A resident's POLST form was found incomplete, missing the date of signature, signee relationship, and physician's documentation and signature. This oversight was confirmed by the Medical Records Director, RN, and DON, posing a risk of treating the resident as full code in emergencies, contrary to their wishes. The resident, with COPD and intact cognition, had their rights potentially violated due to this documentation lapse.
A facility failed to prevent insects and flies from entering a resident's room, who was dependent on staff and had a tracheostomy. Insects were observed crawling from wall cracks, and a fly was seen over the resident's head, increasing infection risk. The Maintenance Supervisor noted broken window screens and a door gap as entry points for pests, contrary to the facility's pest control policy.
A resident with multiple serious medical conditions requested lighter food, more fruits, and milk with every meal. Despite these requests being documented and recommended by the Registered Dietician, the facility failed to communicate and implement these preferences, as confirmed by interviews and record reviews.
A Nurse Practitioner at the facility falsified progress notes for a resident on three occasions, documenting assessments and vital signs despite the resident not being present in the facility. The Director of Nursing confirmed the resident's absence, and the NP admitted to the false documentation, attributing it to a mistake made during a busy period.
The facility failed to update a resident's care plan to include their food preferences for milk and more fruits with each meal, despite these preferences being documented and recommended by the Registered Dietician. The resident had serious medical conditions and required limited assistance with eating, but the care plan was not updated to reflect their nutritional needs.
The facility failed to provide a safe environment when a stranger entered and stole food from the employee breakroom. Staff interviews revealed that the entrance door is locked at night but unlocked early in the morning, which may have allowed the entry. The Administrator acknowledged the incident and the potential risk to residents and staff.
A facility failed to ensure a skin assessment was accurately completed for a resident with multiple medical conditions. The resident had redness and small red bumps on her back and left shoulder, which were not identified during a weekly summary assessment. The issue was discovered during an interview and physical examination, leading to a diagnosis of dermatitis by a dermatologist.
Late Documentation of Insulin Administration on MAR
Penalty
Summary
The deficiency involves the failure of a registered nurse to document insulin administration on the Medication Administration Record (MAR) immediately after giving the medication. The resident involved was admitted with diagnoses including cerebral infarction, diabetes mellitus, and hypertension, and had intact cognition, was independent with eating and oral hygiene, and required moderate assistance with some activities of daily living. The resident had an order for insulin lispro to be administered subcutaneously per sliding scale before meals and at bedtime for diabetes management. Review of the MAR for the month showed multiple instances where insulin lispro doses scheduled for specific times were documented as administered significantly later than the scheduled times. During interviews and concurrent record reviews, the RN who documented the insulin administrations stated that insulin was actually given at the scheduled times but that documentation was completed late. The RN explained that blood sugar was typically checked about 30 minutes before dinner and insulin lispro was administered right before the resident ate, but the MAR entries were made after the fact rather than immediately following administration. The DON confirmed that licensed nurses are expected to document medication administration right after giving all medications. The facility’s medication administration policy specified that medications are to be administered within 60 minutes of the scheduled time, except for before- or after-meal orders, and that the person administering the medication must record the administration on the MAR directly after the medication is given and review the MAR at the end of each pass to ensure doses were administered and documented.
Failure to Document and Investigate Family Grievance per Facility Policy
Penalty
Summary
The facility failed to follow its grievance policy and procedure by not documenting and investigating a grievance submitted on behalf of a resident’s family member. The resident was admitted with diagnoses including cerebral infarction, diabetes mellitus, and hypertension, and had intact cognition per the MDS, requiring varying levels of assistance with activities of daily living. Review of the grievance binder for the relevant period showed no grievance filed for this resident. The Social Services Director stated that any concerns or complaints received from staff or residents should result in completion of a grievance form, communication with social services for follow-up and documentation, and logging into the grievance binder. The DON similarly stated that all complaints should be documented in the grievance binder and that the Administrator, DON, and Social Services Director were designated grievance coordinators who should be informed so an investigation could be started right away. The family member reported sending an email to the facility outlining concerns about the resident’s care and receiving an email response from the Administrator acknowledging receipt the same day. The family member stated that no one from the facility informed the family about what had been done to address their concerns. The Administrator later confirmed receiving the email regarding the family’s concerns but acknowledged that the concerns were not placed on a grievance form and that no investigation was initiated at that time. Review of the facility’s grievance/concern policy indicated that upon receipt of a grievance or concern, a grievance/concern form must be initiated by the staff member receiving the concern and documented on the grievance/concern log. The resident rights policy stated that residents have the right to voice grievances without discrimination or reprisal and to have the facility respond to their grievances. These required steps were not followed for the grievance submitted on behalf of this resident’s family member.
Failure to Provide Written Baseline Care Plan Summary to Resident
Penalty
Summary
The facility failed to provide a written summary of a baseline care plan to a resident and/or the resident’s representative following admission. A resident was admitted with diagnoses including cerebral infarction (stroke), diabetes mellitus, and hypertension. The resident’s MDS assessment showed intact cognition, independence with eating and oral hygiene, and a need for moderate assistance with toileting, showering, and dressing. An Interdisciplinary Care Conference (ICC) note dated shortly after admission documented that the checkbox indicating a copy of the care plan was provided to the resident or representative was left blank. During an interview and concurrent record review, the Case Manager was unable to recall whether a written baseline care plan summary had been provided and could not locate any documentation confirming that it had been given to the resident or family. In a subsequent interview and record review, the DON confirmed that the facility’s practice was to develop a baseline care plan within 48 hours of admission and to provide a written summary of that plan to the resident and/or family. The DON reviewed the ICC notes and clinical record for the resident and was unable to find any indication that a written baseline care plan summary had been provided. Review of the facility’s baseline care plan policy, last revised for 1/2026–1/2027, showed that it required development and implementation of a baseline care plan within 48 hours of admission but did not specify the requirement to provide a written summary to the resident or family, even though the DON stated that copies of the baseline care plan summary should be provided. The absence of documentation and the unmarked ICC checkbox demonstrated that the resident and/or representative did not receive the required written baseline care plan summary.
Improper Use of Low Air Loss Mattress for Resident With Stage III Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper use of a low air loss mattress (LALM) for a resident with a sacrococcygeal stage III pressure injury. The resident was admitted with osteoarthritis of the left knee, a left artificial knee joint, and a stage III sacral pressure ulcer, and had intact cognition per the MDS. The physician’s orders and the care plan included use of a LALM with settings based on the resident’s comfort and/or weight, and monitoring for proper settings and functionality, with the goal that the resident would not have further skin breakdown by monitoring the LALM in the correct setting. During observation, the resident was found lying on a LALM while wearing an incontinence brief, with a flat sheet and a cloth incontinence linen pad underneath, resulting in four layers of linen between the resident and the mattress. During interviews, CNA staff stated that the resident was on the LALM due to an open wound on the resident’s bottom and acknowledged that there were four layers of linen under the resident, while indicating there should only be one layer between the resident’s skin and the LALM. The DSD stated that for residents on a LALM, only flat sheets should be used and staff should use either disposable pads or an incontinence brief, but not both at the same time, and that there should be no more than two layers of linen between the bed and the resident for the LALM to function appropriately. The DON stated that LALMs are used primarily for skin management and that using more than two layers of linen would defeat the purpose of the LALM and delay wound healing. The DON also stated the facility did not have a policy and procedure specific to LALM use, and the existing pressure ulcer/skin breakdown protocol only generally referenced physician orders for pressure reduction surfaces without detailing LALM application or linen use.
Lack of Policies and Procedures for Low Air Loss Mattress Use
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement policies and procedures for the use of low air loss mattresses (LALM) for all 12 sampled residents who were using these specialty beds for pressure ulcer/injury (PU/PI) prevention and treatment. Record review of the facility’s Order Listing Report showed that each of the 12 residents had active physician orders for LALM, with start dates ranging from the prior year to the current month. During observation, all 12 residents were confirmed to be on LALM, and the treatment nurse stated that the mattresses were being used to prevent pressure ulcers and promote wound healing for residents with existing pressure ulcers. In interviews, the DON acknowledged that the facility did not have any written policy or procedure governing LALM use, including guidance on linen use with the mattresses, and stated that the facility followed the manufacturer’s guidelines. However, the manufacturer’s guidelines provided did not address linen use with LALM. The administrator also stated that the facility should have a policy and procedure for LALM use to guide management of residents on these mattresses and noted that many residents were using them. Review of the DON and administrator job descriptions showed that both positions were responsible for developing, maintaining, and ensuring implementation of facility policies and procedures, including nursing policies that conform to current standards and regulations.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach while the resident was in bed. The resident had been admitted with multiple diagnoses, including metabolic encephalopathy, functional quadriplegia, type 2 diabetes, hypertension, and difficulty swallowing. The resident’s History and Physical documented that the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition. The MDS further showed the resident required supervision with eating and oral hygiene, moderate assistance with upper body dressing and personal hygiene, and maximal assistance with toileting hygiene, lower body dressing, and footwear. During an observation and interview in the resident’s room, the resident was found lying in bed, stating they required staff assistance with changing soiled briefs, and the call light was observed on the bedside table out of the resident’s reach. In a concurrent observation and interview, an LVN confirmed that the call light was out of reach and acknowledged it should be within the resident’s reach at all times. Later, a CNA reported that at the start of the shift he ensures residents’ call lights are within reach but stated he must have forgotten to check this resident’s call light position, and reiterated that all call lights should remain within residents’ reach so they can call for assistance when needed. The DON stated that call lights need to be within reach of all residents to enable them to call for assistance when needed and acknowledged that when a call light is out of reach there is a potential for delayed care, increased risk of falls, and decreased feelings of self-worth, self-esteem, and dignity. Review of the facility’s Call System policy indicated each resident is to be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and the floor, and the Dignity policy stated residents are to be treated with dignity and respect in a manner that promotes individuality, well-being, satisfaction with life, self-worth, and self-esteem.
Improper Application and Monitoring of AFO for Resident With Limited Mobility
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure proper application and monitoring of an ankle foot orthosis (AFO) as ordered by the physician for a resident with significant neurological and medical conditions. The resident had a history of traumatic brain injury, seizures, hydrocephalus, type 2 DM, and difficulty swallowing, and the H&P documented that the resident lacked capacity to understand and make decisions. A physician order dated 6/9/2025 directed that bilateral AFOs be placed on the resident’s lower extremities five times per week for 4–6 hours as tolerated, with skin checks. During an observation in the resident’s room, the resident was found lying in bed with an AFO on the right foot and ankle that was rotated to the side and not providing the intended support. During a concurrent observation and interview at the bedside, the Director of Rehabilitation confirmed that the right AFO was not applied properly and stated that the brace should be supporting the right foot and ankle to prevent further foot drop. Later, the RNA reported that he had applied the right AFO that morning in accordance with the physician’s order but was unaware that it was not correctly positioned, and acknowledged that the AFO should remain in the correct position on the foot and ankle. The DON also stated that the AFO should remain correctly positioned at all times and that staff should monitor both the placement of the AFO and the resident’s skin condition while it is in place. Facility policies on assistive devices and on resident mobility and ROM required that staff be trained and competent in the use of devices and that residents with limited mobility receive appropriate services and equipment based on professional standards of practice, but the observed improper application of the AFO demonstrated noncompliance with these requirements.
Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. For two residents with seizure disorders and severely impaired cognitive skills, the facility did not ensure that bed siderails were fully covered with padding as ordered by their physicians and outlined in their care plans. Observations revealed that one resident's bed rail padding had slipped, leaving hard rails exposed, and another resident's bed rail had no padding on one side. In both cases, nursing staff confirmed that the padding was necessary to protect the residents from injury during seizures, in accordance with physician orders and care plans. Additionally, the facility did not provide a required floor mat for a resident with impaired mobility and multiple medical conditions, including respiratory failure and cancer. This resident was found on the floor without a floor mat in place, despite a physician order and care plan intervention indicating its necessity for injury prevention. The resident's bed was positioned against the wall, and the room had low lighting with curtains drawn, making it difficult to see the resident from the hallway. Nursing staff acknowledged that the floor mat should have been present and that the room should have been better lit with curtains open for visibility. The facility's own policies and procedures require the prevention or reduction of hazards associated with bed rails, the provision of a safe and homelike environment, and adequate lighting to promote safety. The failure to follow these policies, physician orders, and care plan interventions resulted in an environment that placed the affected residents at increased risk for injury.
Failure to Follow Physician's Order for Apical Pulse Prior to Heart Medication Administration
Penalty
Summary
A licensed vocational nurse (LVN) failed to follow a physician's order requiring the measurement of a resident's apical pulse prior to administering Flecainide, a heart medication. The resident, who had a diagnosis of atrial fibrillation and was cognitively intact, had a physician's order specifying that Flecainide should be held if the apical pulse was less than 60 beats per minute. Despite this, the LVN did not take the apical pulse before administering the medication on multiple occasions, as evidenced by the Medication Administration Records (MAR) for March, April, and May, which showed no documentation of the apical pulse being taken prior to administration. During a medication pass observation, the LVN was seen taking only the resident's blood pressure and radial pulse before giving Flecainide, and stated there was no need to check anything else. When questioned, the LVN indicated he was unaware of the order to check the apical pulse and had never done so for this resident before administering the medication. The LVN also stated that the electronic medical record system did not prompt for an apical pulse entry, and believed that the order should have been entered with a parameter requiring this check. The Director of Nursing (DON) and the facility's Pharmacist Consultant both confirmed that the apical pulse should have been checked and documented prior to each administration of Flecainide, as per the physician's order and pharmacy recommendations. The DON verified that the medication was given without the required apical pulse check on multiple occasions. The LVN's competency records indicated training on following medication parameters, but this was not adhered to in practice. The facility's policy required medications to be administered according to physician orders, which was not followed in this instance.
Failure to Timely Replace and Document Emergency Medication Kits
Penalty
Summary
The facility failed to ensure timely replacement and proper documentation of emergency medication kits (E-kits) in both the Subacute and Skilled Nursing Facility Medication Rooms, as required by facility policy. In the Subacute Nursing Station, documentation indicated that two vials of Ceftazidime were removed from the E-kit for a resident with sepsis, but subsequent interviews revealed that the medication was not actually removed and the documentation was incorrect. Additionally, the E-kit was not exchanged within the required 72-hour timeframe after being opened, and the pharmacy was not notified promptly for replacement. In the Skilled Nursing Facility Medication Room, the E-kit was found to be opened without the appropriate yellow zip tie or documentation indicating medication removal, and the pharmacy was not notified for replacement as per policy. A resident involved had been admitted with sepsis and was severely cognitively impaired, requiring total assistance for daily activities. Physician orders indicated the need for intravenous antibiotics, and the facility's failure to follow procedures for E-kit management had the potential to delay access to critical medications. Staff interviews confirmed lapses in following the established process for E-kit documentation, notification, and replacement, as outlined in the facility's policy and procedure.
Failure to Check Apical Pulse Before Administering Heart Medication
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to check a resident's apical pulse prior to administering Flecainide, a heart medication, as required by the physician's order. The resident, who had a diagnosis of atrial fibrillation and was cognitively intact, had a specific order to hold the medication if the apical pulse was less than 60 beats per minute. Despite this, the LVN administered the medication without taking the apical pulse, relying only on the radial pulse and blood pressure measurements. Review of the Medication Administration Records (MAR) for three consecutive months showed that the apical pulse was not taken before administering Flecainide on multiple occasions. The MARs for March, April, and May indicated repeated failures to document the apical pulse prior to medication administration, confirming that this was an ongoing issue rather than an isolated incident. The resident's care plan also specified the need to assess and monitor vital signs as ordered, which was not followed in practice. Interviews with the LVN and the Director of Nursing (DON) revealed that the LVN was unaware of the requirement to check the apical pulse and that the electronic medical record system did not prompt for this parameter. The facility's policy required medications to be administered according to physician orders, but this was not adhered to in the case of this resident. The facility pharmacist had also recommended that the apical pulse be checked before administering Flecainide, but this recommendation was not implemented prior to the survey.
Puree Diet Food Served with Incorrect Consistency
Penalty
Summary
Seven of eight residents on a puree diet were served a puree lemon crisp dessert that was too thick in consistency. During a test tray observation, the Dietary Supervisor (DS) and Regional Dietary Supervisor (RDS) confirmed that the dessert did not meet the required texture for a puree diet, as it was too thick and failed the spoon tilt test, which is used to assess the appropriateness of food texture for individuals with dysphagia. The DS stated that the dessert should be smooth, similar to mashed potatoes, and should slide off the spoon easily, but the observed dessert did not meet these criteria. A review of the facility's diet manual for the Dysphagia Diet, Puree IDDSI Level 4, indicated that all puree foods should be lump-free, not firm or sticky, and should pass both the fork drip and spoon tilt tests before being served. The manual also specified that all prepared recipes should be tested prior to service to ensure they meet IDDSI guidelines. The DS acknowledged that the dessert served did not comply with these requirements, which could result in residents having difficulty swallowing.
Deficient Food Storage, Temperature Monitoring, and Staff Hygiene in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and staff hygiene. Bell peppers stored in the walk-in refrigerator were not labeled with the date they were placed inside, contrary to facility policy requiring all foods to be labeled and dated to prevent cross contamination. Additionally, during a tray line observation, staff failed to check the temperatures of several food items, including mashed potatoes, gravy, various modified diet potatoes, chicken, pasta, and carrots. Both the Dietary Supervisor and the staff member acknowledged that all food temperatures should have been taken to ensure proper hot and cold holding, as outlined in facility policy. Further, a Dietary Aide was observed touching his face and eyeglasses with a gloved hand during food service and did not immediately wash hands or change gloves until prompted by the Dietary Supervisor. Both the Dietary Supervisor and the aide confirmed that hand washing and glove changes are required after touching the face, in accordance with facility policy. These deficiencies were identified during observations and interviews, and the facility's policies were reviewed to confirm the requirements that were not followed.
Failure to Implement Individualized Care Plans for Oral Care and Fall Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with individualized oral care interventions for a resident with a tracheostomy who was dependent on a ventilator. The resident was observed with very dry, cracked lips and a thick layer of dry crust, and was seen rubbing her lips with her hand. During interviews and record reviews, nursing staff confirmed that there was no care plan or intervention in place for oral care, despite the resident's dependence on staff for all activities of daily living and the facility's own policies requiring individualized care plans and oral hygiene support for residents unable to perform these tasks independently. Additionally, the facility failed to implement a care plan intervention for another resident who required a floor mat for injury prevention as ordered. The resident, who had diagnoses including respiratory failure, cancer of the larynx, and dysphagia, was found on the floor without a floor mat in place, despite an active order for one to be provided on the left side of the bed. Nursing staff confirmed that the floor mat was not present, and the care plan indicated the intervention should be in place if indicated. Both deficiencies were identified through direct observation, interviews with nursing staff, and review of facility policies and resident records. The facility's policies require ongoing assessment and revision of care plans to meet residents' medical, physical, and psychosocial needs, including specific protocols for oral care and fall prevention, which were not followed in these cases.
Improper Enteral Medication Administration and Inadequate Tube Flushing
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to follow proper technique during medication administration through an enteral tube for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The LVN crushed magnesium oxide and zinc tablets, placed them in separate medication cups with water, and administered them via the resident's enteral tube. After administration, excess crushed medication remained in both cups, indicating the resident did not receive the full prescribed dose. Additionally, the LVN flushed the enteral tube with only 10 milliliters of water between medications, despite a physician's order specifying a 15 milliliter flush between each medication. The resident's medical records confirmed the presence of an enteral tube and orders for medication administration, including the required flush volume. Both the LVN and the Director of Nursing acknowledged during interviews that the full dose of medication should be administered and the tube should be flushed with the ordered amount of water to ensure proper delivery and prevent tube clogging. Facility policies also required adherence to prescriber orders for medication administration and flushing volumes.
Failure to Provide Oral Hygiene for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary oral hygiene services to a resident who was completely dependent on staff for all activities of daily living. The resident, who had diagnoses including hemiplegia, respiratory failure with hypoxia, dysphagia, and was dependent on a ventilator and feeding tube, was observed lying in bed with very dry, cracked lips covered by a thick layer of dried saliva and skin. The resident was unable to communicate effectively and required total assistance for hygiene and movement. During the observation, a registered nurse acknowledged the resident's lips were very dry and in need of oral care, noting the potential for bleeding or pain and the possible impact on the resident's feelings. Facility policies reviewed indicated that residents unable to perform ADLs independently should receive appropriate care, including oral care, and that care should promote well-being and dignity. However, the observed condition of the resident's lips demonstrated that these services were not provided as required.
Failure to Maintain Proper Catheter Tubing Positioning
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, neuromuscular bladder dysfunction, and urinary retention was admitted with an indwelling urinary catheter. The resident was dependent on staff for all activities of daily living, including hygiene and toileting, and had documented episodes of confusion. The resident had a physician order for a urinary catheter due to retention and neurogenic bladder, and had experienced urinary tract infections (UTIs) on two separate occasions during their stay. During an observation, the resident was found lying in bed with the urinary catheter bag improperly positioned and the catheter tubing exhibiting a long dependent loop, two coils, and a kink. The tubing contained yellow liquid with white sediments. Both the Minimum Data Set Coordinator and a registered nurse confirmed that the catheter tubing should not be looped, coiled, or kinked, as this can impede urine flow and increase infection risk. Facility policy required catheter tubing to be kept free of kinks to maintain unobstructed urine flow, but this was not followed in the resident's care.
Failure to Document Post-Dialysis Weight for Resident Receiving Hemodialysis
Penalty
Summary
The facility failed to ensure that a post-dialysis assessment was completed for a resident with end stage renal disease who required hemodialysis. Specifically, on 5/15/2025, the dialysis center did not record the resident's post-dialysis weight on the Dialysis Communication Record. This omission was verified during record reviews and interviews with both a registered nurse and the Director of Nursing, who confirmed that the post-dialysis weight was missing and that the facility's protocol required staff to contact the dialysis center to obtain this information if it was not documented. The resident involved was severely cognitively impaired and dependent on staff for daily activities, as indicated by the Minimum Data Set. The resident's care plan required pre- and post-dialysis weights to be taken at the dialysis center to help avoid fluid overload. Facility policy and licensed nurse competency guidelines both specified that missing post-dialysis weights should be immediately followed up with the dialysis center, but this was not done, resulting in incomplete documentation for the resident's dialysis care on the specified date.
Unlabeled and Unpackaged Tablet Found in Medication Cart
Penalty
Summary
A deficiency was identified when, during an observation and interview with an LVN at one of the medication carts, a white, round, unlabeled and unpackaged tablet was found in the bottom of a cart drawer. The LVN confirmed that medications should be packaged and labeled when stored in the cart to ensure the correct medication is administered and to verify expiration dates. The DON also stated that all medications should be packaged and labeled to prevent accidental administration to the wrong resident and to reduce medication errors. Review of the facility's policy indicated that medications are to be kept in containers that meet legal requirements and that contaminated medications are to be immediately removed and disposed of.
Inaccurate Documentation of Advance Directive Status
Penalty
Summary
The facility failed to ensure the accuracy of a medical record for one resident when the Advance Directive Acknowledgement form incorrectly indicated that the resident had an Advance Directive, despite no such document existing. The resident in question was admitted with diagnoses including pneumonia, bipolar disorder, and schizophrenia, and was noted to be deaf and non-speaking. The Minimum Data Set assessment indicated that no Advance Directive was completed for this resident. Additionally, a letter from the regional center clarified that the resident was not capable of providing informed consent, had no court-appointed conservator or guardian, and that a regional center designee would provide consent for medical treatments. During interviews, the responsible party from the regional center confirmed there was no Advance Directive for the resident, and the Social Services Director acknowledged that the Advance Directive Acknowledgement form was incorrect. The facility's policy required staff to inquire about the existence of an Advance Directive upon admission and to document its presence or offer the opportunity to create one if it did not exist. However, the documentation in the resident's medical record inaccurately reflected the existence of an Advance Directive, resulting in a deficiency related to the maintenance of accurate medical records.
Failure to Develop Comprehensive Care Plan for Resident's Food Preference
Penalty
Summary
The facility failed to develop a comprehensive care plan with resident-centered interventions for a resident who preferred to keep food at their bedside. The resident, who was readmitted to the facility with diagnoses including chronic obstructive pulmonary disease, noncompliance with medical treatment, and functional quadriplegia, was observed to have two eggs wrapped in plastic on their bedside table. The resident expressed a preference for keeping food at their bedside, which was confirmed by the Dietary Supervisor. The Director of Nursing acknowledged that the resident's care plan, revised on 2/6/2025, did not include specific interventions related to the resident's preference for keeping food at the bedside. The facility's policy requires the Interdisciplinary Team to develop individualized comprehensive care plans, but this was not done in this case. The lack of specific interventions in the care plan had the potential to negatively affect the resident's quality of life and care.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident, identified as Resident 3, upon their discharge. Resident 3 was readmitted to the facility with diagnoses including cervical disc degeneration, a laceration on the head, and a history of falling. The Minimum Data Set (MDS) indicated that the resident had intact cognition. Despite these details, there was no documented evidence of a discharge summary being completed when Resident 3 was discharged from the facility. Interviews with the Medical Records Director and the Director of Nursing revealed that a discharge summary should have been documented upon the resident's discharge, as per the facility's policy. The discharge summary is intended to provide a summary of the services provided and the resident's condition during their stay, and it is crucial for ensuring consistent care coordination. The facility's policy mandates that a discharge summary be completed within 30 days of discharge, but this was not adhered to in the case of Resident 3.
Failure to Document Resident's Fluid Intake
Penalty
Summary
The facility failed to implement its hydration and prevention of dehydration policy by not ensuring that a resident's fluid intake was documented in the medical record. This deficiency was identified for a resident who was admitted with osteomyelitis, low back pain, and chronic kidney disease, and who had severely impaired cognition requiring assistance with daily activities. The facility's policy required that intake be documented in medical records and that aides report intake of less than 1,200 mL/day to nursing staff. Interviews with staff revealed that Certified Nursing Assistants (CNAs) did not document residents' fluid intake in milliliters, and there was no specific area in the medical records for such documentation. The Director of Nursing confirmed that unless there was an intake and output order or fluid restrictions, fluid intake was not documented. This lack of documentation had the potential to place the resident at risk for dehydration and related medical complications.
Failure to Discard Perishable Food Puts Resident at Risk
Penalty
Summary
The facility failed to adhere to its policy on preventing foodborne illness by not ensuring that cooked eggs found on a resident's bedside table were discarded after being left out for over 24 hours. The resident, who was readmitted to the facility with chronic obstructive pulmonary disease and functional quadriplegia, was observed to have two hard-boiled eggs wrapped in plastic on their bedside table. These eggs were labeled with a date indicating they had been there since the previous day. The resident confirmed that the eggs had not been refrigerated and had been at their bedside since the previous day. The Dietary Supervisor acknowledged that the resident receives cooked eggs as a snack upon request and confirmed that cooked eggs should be refrigerated if not consumed immediately. The facility's policy, reviewed in July 2024, states that food served without temperature controls should be discarded if not eaten within two hours to minimize the risk of foodborne illness. The Dietary Supervisor reiterated that cooked eggs are perishable and should be discarded after two hours if not refrigerated, as they could lead to bacterial growth. This oversight placed the resident at risk for foodborne illnesses.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) and Hand Hygiene (HH) policies, leading to a deficiency in infection control practices. Certified Nurse Assistant 1 (CNA 1) did not don a gown while changing the bed linen for a resident on EBP, despite the signage on the resident's door indicating the requirement to wear a gown and gloves for such tasks. Additionally, CNA 1 did not perform hand hygiene after removing gloves, which is a critical step in preventing the spread of infections. The resident involved was admitted with diagnoses including idiopathic peripheral autonomic neuropathy, diabetes mellitus with a skin ulcer, and cellulitis of the lower limb. The resident's Minimum Data Set indicated intact cognition and a need for maximum assistance with personal hygiene and moderate assistance with bed mobility. Physician orders specified enhanced barrier precautions due to the resident's risk of infection from wounds. Interviews with facility staff, including CNA 1, Licensed Vocational Nurse 2 (LVN 2), the Infection Prevention Nurse (IP), and the Director of Nursing (DON), confirmed the failure to adhere to the facility's policies. The facility's policy required staff to wear gowns and gloves during high-contact activities, such as changing bed linens, to prevent the transmission of multidrug-resistant organisms. The policy also mandated hand hygiene after removing personal protective equipment, which was not followed in this instance.
Failure to Maintain Required Room Temperature
Penalty
Summary
The facility failed to maintain the required room temperature levels between 71-81 degrees Fahrenheit for residents, as observed in two rooms and affecting one resident. During an observation, Room A was found to have a temperature of 65 degrees F, and Room B had a temperature of 69.5 degrees F. The Maintenance Supervisor confirmed that the resident rooms are required to be within the specified temperature range and acknowledged the need to adjust the thermostat to meet these requirements. Resident 3, who was admitted with diagnoses including a left pelvic fracture, left hip fracture, heart failure, and insomnia, reported discomfort due to the cold room temperature. The resident was observed using an extra blanket to keep warm, indicating the room's temperature was below the required level. The facility's policy on providing a homelike environment also specifies maintaining a comfortable and safe temperature range, which was not adhered to in this instance.
Improper Placement of Power Strips Creates Hazards
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the safe placement of power strips, leading to potential hazards for residents, visitors, and staff. During a facility tour, it was observed that a power strip was placed on the floor next to a resident's bed, creating a tripping hazard. Additionally, another power strip was improperly secured to a bed rail using plastic gloves, which was acknowledged by the Maintenance Supervisor as not being secured properly. These observations were made in the rooms of two residents, both of whom had intact cognition and the capacity to understand and make decisions. The facility's policy, revised in July 2024, clearly states that power strips should not be mounted to any permanent structure and must be stored in a manner that does not create a tripping hazard. Despite this, the power strips were not stored safely, posing an increased risk of falls, trips, and occupational hazards. The Administrator confirmed that the power strips should not be lying on the floor or tied to bed rails with plastic gloves, indicating a lapse in following the established guidelines for maintaining a safe environment.
Failure to Conduct Neurological Assessment After Unwitnessed Fall
Penalty
Summary
The facility failed to adhere to its policy and procedure on Fall Management and Neurological Evaluation by not completing a neurological assessment after an unwitnessed fall involving a resident. The resident, who had been admitted with diagnoses including sepsis, autonomic neuropathy, muscle weakness, and repeated falls, experienced an unwitnessed fall on 8/17/2024. Despite the facility's protocol requiring a neurological assessment for 72 hours post-fall, this was not conducted, potentially leading to a delay in care and placing the resident at risk. Interviews and record reviews revealed that the MDS Nurse acknowledged the requirement for a neurological assessment following an unwitnessed fall, which should be performed by licensed nurses without needing a physician's order. However, the assessment was not completed, and the resident was transferred to the hospital for evaluation. Upon the resident's return to the facility, the neurological assessment was not resumed, as the Director of Nursing incorrectly believed that a physician's order was necessary to continue the assessment. The facility's policies on Fall Management and Neurological Evaluation clearly state the need for immediate and ongoing neurological checks following an unwitnessed fall. Despite this, the Neurological Flow Sheet for the resident was not completed, and the Director of Nursing maintained that the facility staff did not err, citing the absence of a physician's order as the reason for not continuing the assessment. This oversight resulted in incomplete documentation and monitoring of the resident's condition post-fall.
Failure to Ensure Timely Pain Management for a Resident
Penalty
Summary
The facility failed to implement its pain management policy by not ensuring timely notification of the physician to obtain orders for treating a resident's pain. The resident, who was admitted with conditions including sepsis, autonomic neuropathy, muscle weakness, and repeated falls, required substantial assistance with daily activities. Despite having orders for pain medications such as Acetaminophen, Gabapentin, and Tramadol, the resident continued to experience pain. On a specific day, the resident complained of pain, and the Licensed Vocational Nurse (LVN) attempted to contact the on-call physician for additional pain medication but faced technical difficulties with the phone service. The LVN did not take further action to resolve the issue, such as contacting the medical director, and instead endorsed the situation to the next shift. The Director of Nursing later stated that the LVN should have informed them, so they could have contacted the medical director. The facility's pain management policy, last reviewed in July 2024, emphasizes maintaining the highest possible level of comfort for residents by providing a system to identify, assess, treat, and evaluate pain, which includes notifying the physician and obtaining treatment orders as needed.
Delayed Food Preference Assessments for New Residents
Penalty
Summary
The facility failed to complete food preference assessments within 48 hours of admission for four out of five sampled residents, as required by their policy and protocol. This deficiency was identified through observation, interviews, and record reviews. The residents involved had various medical conditions, including diabetes mellitus, cerebral infarction, right hemiplegia, displaced intertrochanteric fracture, depression, and osteoarthritis. Despite having intact cognition or mild cognitive impairment, their food preference interviews were delayed, being conducted on the same date, well beyond the 48-hour requirement. During interviews, both the Dietary Supervisor and the Dietician acknowledged the failure to adhere to the facility's policy, which mandates that food preference interviews be completed within 48 hours of a resident's admission. They recognized that this oversight could lead to residents being served food they do not prefer, potentially resulting in decreased meal intake and weight loss. The facility's policy, reviewed in July 2024, clearly states the necessity of identifying individual dining, food, and beverage preferences promptly upon admission.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for three residents, which could potentially delay care and leave residents' needs unmet. Resident 2, who was admitted with dementia and heart failure, was observed with the call light on the floor, out of reach. The Infection Preventionist confirmed that the resident would be unable to call for assistance, increasing the risk of accidents if the resident attempted to go to the bathroom unassisted. Resident 7, admitted with spinal stenosis and difficulty walking, was found asleep in bed with the call light hanging off the back of the bed, out of reach. A Certified Nursing Assistant verified this observation. The Director of Nursing stated that staff are trained to ensure call lights are within reach, emphasizing the importance of timely response to emergencies to prevent accidents. Resident 70, who was totally dependent on assistance for mobility and personal hygiene, was observed waving to get attention as the call light was wrapped around the side rails and not within reach. A Registered Nurse and a Certified Nursing Assistant confirmed the situation, noting the importance of the call light being accessible to prevent skin problems from prolonged soiling and resident frustration.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that the clinical records of four residents were updated with their advance directives, which are crucial documents outlining a person's medical treatment preferences in situations where they cannot communicate their wishes. Resident 26, who was admitted with a diagnosis of sepsis and had moderate cognitive impairment, had executed an advance directive, but the facility was still waiting for the family to provide a copy. The Social Service Director (SSD) acknowledged that no follow-up had been conducted with the family to obtain the document. Similarly, Resident 58, who had intact cognition and was admitted with multiple sclerosis and benign prostatic hyperplasia, had also executed an advance directive. However, the facility had not received a copy from the family, and no follow-up was done. The SSD reiterated the importance of having advance directives to ensure residents' wishes are honored, especially in emergencies. Resident 29, with severely impaired cognition and a history of rhabdomyolysis, bipolar disorder, and dementia, had an advance directive executed by a surrogate decision maker, but it was missing from the medical record. Resident 82, with intact cognition and a diagnosis of chronic obstructive pulmonary disease, also had an advance directive that was not present in their medical chart. The SSD and Medical Records Director confirmed the absence of these documents, emphasizing the dignity issue and the necessity of honoring residents' wishes as per the facility's policy.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. Resident 82, who was admitted with chronic obstructive pulmonary disease, was receiving antibiotics for a urinary tract infection but did not have a care plan in place for the antibiotic use. This lack of a care plan meant there were no specified goals, interventions, or monitoring processes to ensure the effectiveness of the treatment, potentially delaying the resident's healing process. Resident 30, who had diagnoses including abnormalities of gait and mobility, did not have a care plan that accurately reflected the physician's orders for Restorative Nursing Assistant exercises. Although the resident had orders for active range of motion exercises for both upper and lower extremities, the care plan only included exercises for the lower extremities. This discrepancy could lead to missed interventions by the interdisciplinary team, risking functional decline for the resident. Resident 32, admitted with obstructive and reflux uropathy, did not have a care plan for urinary retention despite having a diagnosis and physician's orders for medication to manage the condition. The absence of a care plan meant there was no structured approach to monitor urinary retention or ensure normal urination, which could impact the resident's care and well-being. The facility's policy requires comprehensive care plans to be developed within seven days of the resident's assessment, but this was not adhered to in these cases.
Incorrect LAL Mattress Settings Increase Pressure Ulcer Risk
Penalty
Summary
The facility failed to ensure that the low air loss (LAL) mattresses were set correctly for three residents, which increased their risk of skin breakdown and pressure ulcers. Resident 29, who was readmitted with conditions including rhabdomyolysis, bipolar disorder, and dementia, had a sacral pressure ulcer classified as stage four. Observations revealed that the LAL mattress was set to static mode and at an incorrect weight setting, which was not adjusted according to the resident's weight and comfort. Treatment Nurse 1 and Treatment Nurse 2 confirmed the incorrect settings and adjusted them accordingly, noting that the static mode and incorrect weight setting could hinder wound healing. Resident 48, admitted with a tracheostomy and traumatic brain injury, was dependent on staff for self-care and mobility and at risk of developing pressure ulcers. The LAL mattress for this resident was observed to be set at the maximum weight setting, which was significantly higher than the resident's actual weight. Treatment Nurse 3 confirmed the incorrect setting and adjusted it to match the resident's weight, acknowledging that the previous setting could increase the risk of pressure ulcers due to the mattress's firmness. Resident 62, who had severely impaired cognition and was dependent on staff for all activities of daily living, was also at severe risk of developing pressure ulcers. The LAL mattress for this resident was set at a weight significantly higher than the resident's actual weight, as indicated by a sticker on the mattress. Registered Nurse 1 confirmed the discrepancy and adjusted the setting to the correct weight. The Director of Nursing stated that incorrect settings on the LAL mattress would defeat its purpose of preventing pressure injuries.
Failure to Attempt Non-Pharmacological Interventions Before Administering Opioid Pain Medication
Penalty
Summary
The facility failed to ensure that licensed nurses attempted non-pharmacological interventions before administering as-needed opioid pain medication to a resident on multiple occasions. This deficiency was identified for a resident who had been admitted with acute respiratory failure, tracheostomy status, and gastrostomy status. The resident had moderately impaired cognition and required maximum assistance for most activities of daily living. The resident's physician had prescribed hydrocodone-acetaminophen to be administered via gastrostomy tube for severe pain, but there was no documentation of non-pharmacological interventions being attempted prior to administering the medication on several dates in April and May 2024. During interviews, both the MDS Nurse and the Director of Nursing acknowledged the importance of attempting non-pharmacological interventions before administering prn pain medication to potentially avoid unnecessary medication and its adverse side effects. The facility's policy on pain management emphasized the need for an individualized care plan that includes both non-pharmacological and pharmacological approaches, and required documentation of non-pharmacological interventions and their effectiveness. However, the lack of documentation indicated that this policy was not followed, leading to the deficiency.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and administration of Zosyn, an antibiotic, for a resident diagnosed with cellulitis. The resident was admitted with conditions including dementia, heart failure, and cellulitis of the left lower limb. The physician's orders required Zosyn to be administered intravenously every eight hours for seven days. However, the Medication Administration Record (MAR) lacked documentation for several doses, and there was no indication of refusal by the resident. This lack of documentation raised concerns about whether the medication was administered as prescribed. Additionally, the facility did not maintain accurate records for controlled drugs for several residents. For one resident with epileptic seizures, there was a discrepancy between the Controlled Drug Record (CDR) and the MAR for lacosamide, a medication administered via PEG tube. The nurse responsible admitted to forgetting to sign the CDR, which is a critical step in the medication administration process. This oversight could lead to medication errors, such as double dosing. Similar discrepancies were found for other residents receiving controlled medications like Norco, morphine sulfate, and tramadol. In each case, the CDR indicated that medications were removed from the bubble pack, but corresponding entries were missing from the MAR. The Director of Nursing confirmed these discrepancies and emphasized the importance of the 'pour, pass, and sign' procedure to prevent medication errors. These lapses in documentation and procedure adherence posed risks of medication errors and potential drug diversion.
Medication Labeling and Access Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which led to several deficiencies. For two residents, insulin medications were not dated when opened, which is crucial to ensure the medication is not used beyond its effective period of 28 days. Resident 12, who was cognitively intact, had a Lantus insulin pen without an open date, and Resident 387, who was severely impaired in cognition, had a lispro insulin vial also lacking an open date. Both instances were observed by a registered nurse, who acknowledged the importance of labeling to maintain medication effectiveness. Additionally, the facility did not ensure that an eye drop medication for Resident 33 was used within its effective period. The latanoprost ophthalmic solution, prescribed for glaucoma, was observed with an open date indicating it was used past the 28-day period. The registered nurse involved was under the impression that the eye drops could be used for 30 days, contrary to the facility's policy, which mandates discarding after 28 days to ensure effectiveness. Furthermore, the facility allowed unauthorized access to a medication room, which could lead to drug diversion. The Dietary Supervisor was observed entering the medication room using an access code, despite facility policies stating that only licensed nurses or staff accompanied by licensed nurses should have access. The Director of Nursing confirmed that unauthorized personnel should not have access to the medication room, as it increases the risk of unauthorized access to medications.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices for three residents, leading to potential health risks. For Resident 187, the nasal cannula tubing was observed touching the floor, which was confirmed by a Certified Nursing Assistant (CNA) and acknowledged by the Infection Preventionist (IP) and the Director of Nursing (DON) as a potential source of contamination. The facility's policy and CDC guidelines emphasize the importance of keeping medical equipment off the floor to prevent bacterial contamination. Additionally, the facility did not label urinals for Residents 187 and 188, which could lead to cross-contamination. During observations, both residents were found with unlabeled urinals, and staff confirmed that labeling is necessary to prevent the use of the same equipment by different residents. The IP and DON both acknowledged the increased risk of infection due to the lack of labeling, and the Administrator admitted there was no specific policy addressing this issue. For Resident 337, the intravenous administration set used to deliver antibiotics was not labeled, which could result in contamination and infection. The Registered Nurse (RN) responsible for administering the medication admitted to dropping the label and not replacing it. The IP confirmed that labeling is crucial for tracking the administration schedule and preventing bacterial transmission. The facility's policy requires labeling of IV sets with specific information, including the date, time, and initials of the administering nurse.
Failure to Maintain Resident Dignity with Catheter Privacy
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter collection bag was covered with a privacy bag for a resident, which compromised the resident's dignity. The resident, who was admitted with diagnoses of multiple sclerosis and benign prostatic hyperplasia, had the capacity to make decisions and intact cognition. Despite these considerations, the resident's urinary catheter bag was observed without a dignity bag, making the urine visible. During an observation and interview with the Infection Preventionist, it was confirmed that the resident's drainage bag lacked a dignity bag, which is necessary for maintaining resident dignity and infection control. The facility's policy on Quality of Life - Dignity, last reviewed in July 2023, mandates that residents be cared for in a manner that promotes their well-being and self-esteem, including maintaining privacy during personal care and treatment procedures.
Failure to Timely Collect and Follow-Up on STAT Fecal Occult Blood Test
Penalty
Summary
The facility failed to ensure timely collection and follow-up of a STAT fecal occult blood test (FOBT) for Resident 25, who was admitted with Guillain-Barre syndrome and myasthenia gravis. On 6/5/2024, a STAT order for a complete blood count (CBC), basic metabolic panel (BMP), and FOBT was placed after the family reported the resident had a soft black stool, indicating potential internal bleeding. However, the stool specimen was not collected during the resident's bowel movement at 9:32 p.m. on the same day, and the order was marked as incomplete and rescheduled for 6/7/2024. The stool specimen was eventually collected on 6/7/2024, but there was no documentation of follow-up on the FOBT result until 6/10/2024. During this period, the resident's hemoglobin levels dropped significantly, indicating worsening anemia. On 6/10/2024, the resident was found to have a positive FOBT and critically low hemoglobin, prompting an emergency transfer to the hospital. The delay in collecting the stool specimen and following up on the test results contributed to the resident's deteriorating condition. Interviews with the Registered Nurse (RN) and Director of Nursing (DON) revealed that the facility's policy required STAT orders to be completed within a 4 to 6-hour timeframe. The DON emphasized the importance of timely specimen collection and result follow-up to prevent complications such as hypovolemic shock. The failure to adhere to these protocols resulted in a delay in necessary medical intervention for Resident 25.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, which violated their rights to self-determination and choice. Resident 44, who was admitted for orthopedic aftercare following knee surgery and had undergone gastric bypass surgery, requested cereal for dinner due to a lack of appetite. However, the staff member, [NAME] 1, denied this request, mistakenly believing there was no cereal available. This led to Resident 44 not eating that night as she did not like the alternative meal offered. Similarly, Resident 57, admitted for acute kidney failure, requested hard-boiled eggs for dinner, which was denied by [NAME] 1, who thought there were no eggs available. Instead, [NAME] 1 offered a hamburger from the alternate menu, which Resident 57 declined. The Dietary Supervisor confirmed that both cereal and eggs were available and should have been provided to the residents. The Director of Nursing emphasized the importance of accommodating residents' preferences, especially when dietary restrictions do not prevent it.
Incomplete POLST Documentation for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of the sampled residents, identified as Resident 82. The deficiency was identified during a review of Resident 82's Physician's Order for Life-Sustaining Treatment (POLST) form, which was found to be incomplete. The POLST form, which is crucial for specifying the types of medical treatment a resident wishes to receive during serious illness, was missing the date of the resident's signature, the relationship of the signee, and the physician's documentation of discussion and signature. This incomplete documentation was confirmed during interviews with the Medical Records Director, Registered Nurse 2, and the Director of Nursing, all of whom acknowledged the missing information on the POLST form. Resident 82 was admitted to the facility with a diagnosis of chronic obstructive pulmonary disease (COPD) and had intact cognition as per the Minimum Data Set assessment. The incomplete POLST form posed a risk of violating the resident's rights and preferences regarding treatment, as it would be deemed invalid in an emergency situation, leading to the resident being treated as full code status. The facility's policy on charting and documentation requires that medical records be objective, complete, and accurate, which was not adhered to in this case.
Inadequate Pest Control Measures Lead to Insect Presence in Resident's Room
Penalty
Summary
The facility failed to prevent the presence of insects and flies in the room of a resident who was admitted with cerebral infarction, hemiplegia, and hemiparesis, and was dependent on staff for daily activities. During a visit, a family member observed insects crawling out from small cracks in the walls and reported it to the registered nurse. Additionally, a fly was observed flying over the resident's head during a concurrent observation and interview, posing a risk of infection due to the resident's tracheostomy. The Maintenance Supervisor acknowledged that some windows had bent and broken screens, allowing insects to enter the facility. The pest control company had also noted a door with a gap that could allow insects to enter. The facility's policy indicated that windows should be screened to prevent insect entry, but this was not consistently implemented, contributing to the presence of pests in the resident's room.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, specifically for milk and more fruits with each meal. The resident, who had multiple serious medical conditions including respiratory failure, diabetes mellitus, and bipolar disorder, had requested lighter food, more fruits, and milk with every meal. Despite these requests being documented in the resident's Nutritional Care Assessment and recommended by the Registered Dietician, there was no evidence that these preferences were communicated to or implemented by the dietary department. The lack of documentation and follow-through was confirmed through interviews with the Registered Dietician, Licensed Vocational Nurse, and Dietary Supervisor, who were unable to locate any diet communication slips or records indicating that the resident's food preferences were accommodated. The resident's Minimum Data Set indicated that their cognition was intact, and they required limited assistance with eating. The resident had experienced a 5% weight loss over 90 days, which could be attributed to inadequate oral intake. The facility's policy on Resident Food Preferences required that individual food preferences be assessed upon admission and communicated to the interdisciplinary team, with modifications to the diet ordered with the resident's consent. However, the facility failed to follow this policy, resulting in the resident's food preferences not being met, which had the potential to decrease meal intake and lead to weight loss.
Falsification of Resident Progress Notes by Nurse Practitioner
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner (NP) did not willfully falsify progress notes for a resident on three separate occasions. The resident, who had been admitted with serious conditions including respiratory failure, diabetes mellitus, and bipolar disorder, was not present in the facility on the dates the progress notes were documented. Despite this, the NP recorded detailed assessments and vital signs for the resident on those dates, creating a fraudulent clinical record that inaccurately reflected the care provided. During an interview, the Director of Nursing (DON) confirmed that the resident had been transferred to a General Acute Care Hospital and was not in the facility on the dates the progress notes were made. The DON could not explain how the NP was able to document assessments for the resident during their absence. The NP admitted to completing the progress notes despite the resident not being present and attributed the false documentation to a mistake, stating that the assessments were done from memory after returning home. The facility's policies and procedures require that all services provided to residents and any changes in their condition be accurately documented in their medical records. The NP's actions violated these policies, as the progress notes did not reflect the resident's actual status or care provided. The Primary Care Provider (PCP) also acknowledged that the progress notes were mistakenly completed during a busy period, further highlighting the issue of inaccurate documentation.
Failure to Update Care Plan for Resident's Food Preferences
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan to address and accommodate a resident's food preferences for milk and more fruits with each meal. The resident, who had intact cognition and required limited assistance with eating, had requested lighter food, more fruits, and milk with every meal. Despite these requests being documented in the resident's Nutritional Care Assessment and recommended by the Registered Dietician, the care plan was not updated to reflect these preferences. This oversight was confirmed during interviews with the Registered Dietician, Licensed Vocational Nurse, and Minimum Data Set Nurse, who all acknowledged the absence of an updated care plan addressing the resident's food preferences. The resident's medical history included serious conditions such as respiratory failure with hypoxia, tracheostomy, dependence on a respirator, diabetes mellitus, and bipolar disorder. The facility's policy required that any changes in diet, including food preferences, be documented in the care plan and communicated to the resident's physician. However, the facility did not adhere to this policy, resulting in a failure to implement a comprehensive care plan that met the resident's nutritional needs and preferences.
Stranger Enters Facility and Steals Food
Penalty
Summary
The facility failed to provide a safe and comfortable environment for residents, staff, and the public when a stranger was able to enter the facility and steal food from the employee breakroom. On 1/7/2023, at approximately 1:40 a.m., a suspect entered the break room, took chicken from the refrigerator, ate it, and then left the location. The incident was reported to the police department at 8:20 a.m. the same day. Interviews with staff revealed that the entrance door is locked between 11 p.m. and 11:30 p.m. daily and then unlocked around 3 a.m. for incoming staff, which may have allowed the stranger to enter the facility undetected. During an interview, a Licensed Vocational Nurse (LVN) stated that they found a stranger in the breakroom looking for food but were unsure how the individual gained entry. The Administrator confirmed that the incident should not have occurred and acknowledged the potential risk to residents and staff. A review of the facility's policy on safety and supervision indicated a commitment to making the environment as free from accident hazards as possible, highlighting a failure in the facility's security measures.
Failure to Accurately Complete Skin Assessment
Penalty
Summary
The facility failed to ensure a skin assessment was accurately completed during a weekly summary assessment for Resident 2. Resident 2, who has a medical history including type 2 diabetes, chronic obstructive pulmonary disease, major depressive disorder, hypertension, and difficulty in walking, was admitted from a General Acute Care Hospital. The Minimum Data Set indicated that Resident 2 had moderately impaired cognitive skills and required assistance for daily activities. On a weekly summary assessment, LVN 1 documented that Resident 2 had no skin issues without actually assessing the resident's skin condition. This led to the failure to identify redness and small red bumps on Resident 2's back and left shoulder, which were later observed during an interview and physical examination on 4/10/2024. During interviews, it was revealed that Resident 2 had been experiencing itching on her back but was unsure of the duration. CNA 1 mentioned that Resident 2 preferred bed baths over showers and would notify the charge nurse if a rash was observed. The Director of Nursing was unaware of the skin condition until the interview and subsequently arranged for a dermatologist consultation. The dermatologist diagnosed Resident 2 with dermatitis and prescribed a treatment plan. LVN 1 admitted to not assessing Resident 2's skin during the weekly summary assessment, which was against the facility's policy and procedure for skin integrity management.
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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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