Pioneers Memorial Skilled Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brawley, California.
- Location
- 320 Cattle Call Dr., Brawley, California 92227
- CMS Provider Number
- 555557
- Inspections on file
- 34
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Pioneers Memorial Skilled Nursing Center during CMS and state inspections, most recent first.
Two cognitively impaired residents with extensive fall histories were repeatedly placed in wheelchairs near the nurses’ station without individualized assessment or clear care plan interventions defining their supervision needs. One resident, who was nonverbal, impulsive, and totally dependent for transfers, repeatedly attempted to stand from his wheelchair over an extended early-morning period while an LPN intermittently redirected him but then left his side to perform other tasks; he ultimately stood and fell while staff had their backs turned, sustaining head lacerations and a C1 fracture. The other resident, with Alzheimer’s disease, gait difficulty, and poor safety awareness, had outdated fall risk evaluations and vague fall care plans, and experienced multiple unwitnessed falls, including one from her wheelchair in front of the nurses’ station during shift report that resulted in lumbar compression fractures, and additional unwitnessed falls in common areas. IDT documentation for both residents failed to identify root causes or implement relevant, individualized preventive interventions, and multiple staff reported that there was insufficient staffing to provide the close, frequent monitoring these high-risk residents required.
The facility failed to provide adequate nursing staff and consistent supervision for multiple cognitively impaired, high fall-risk residents who were placed in wheelchairs in front of the nurses’ stations for closer monitoring. One resident with advanced dementia, severe cognitive impairment, impulsive behavior, and a history of multiple falls was repeatedly observed on video attempting to stand from his wheelchair while an LPN intermittently intervened but then left his side to perform other tasks; he ultimately fell and sustained a C1 cervical fracture. Another resident with Alzheimer’s disease, dementia, gait difficulty, and poor safety awareness had numerous falls, including unwitnessed falls in front of the nurses’ station and in common areas, and was later found to have a lumbar compression fracture, while staff reported she needed monitoring at least every 15 minutes but that staffing levels made this impossible. On two units, several residents with dementia, Alzheimer’s disease, Parkinson’s disease, prior fractures, and histories of falls were lined up at the nurses’ stations with no staff in visual range while nurses were at medication carts and CNAs were in resident rooms, and staff and unit managers acknowledged that there were not enough staff to provide the close or 1:1 supervision these residents required and that care plans lacked individualized supervision interventions.
The facility failed to comply with its own policy and regulatory requirements to post and maintain accurate daily nurse staffing information. The DSD reported that the nurse staffing data posted in the lobby and provided for review consisted only of projected hours for RNs, LPNs/LVNs, and CNAs, and that the facility did not have access to actual hours worked because an outside management company handled that information. The interim DON and the administrator both acknowledged that the facility should have access to and post actual hours worked and know whether State-required staffing levels were being met, but this was not occurring, and actual nurse staffing data were not readily available to residents, visitors, or upon request.
The facility failed to revise fall care plans with resident-specific interventions addressing supervision needs for two cognitively impaired residents who experienced multiple falls. One resident with dementia, severe cognitive impairment, and dependence for transfers had numerous witnessed and unwitnessed falls in the room and hallway, yet fall care plans remained generic, focused mainly on post-fall monitoring, and did not address his need for close supervision despite staff acknowledging he could not follow directions or use the call light purposefully. Another resident with Alzheimer’s disease, dementia, gait difficulty, and muscle weakness had repeated falls in the bathroom, room, hallway, in front of the nurse station, and dining room, but her fall risk evaluation was not updated with quarterly MDS assessments, and her fall care plan contained vague interventions such as "initiate fall precautions" and "determine ability to transfer" without clear, specific supervision measures or defined rounding responsibilities. IDT notes after falls lacked root-cause analysis or preventive recommendations, the interim DON reported that falls were not thoroughly investigated, and the medical records director stated there was no policy for care plan development or revision.
A resident with dementia, impulse disorder, anxiety, and a history of falls experienced an unwitnessed fall near the nurse’s station. An RN/unit manager later documented that an IDT, including multiple department leaders, met to review the fall, assess contributing factors, and implement interventions such as 30-minute rounding and floor mats. In interviews, the DSD denied attending any such meeting and stated no IDT was held for the fall. The RN/unit manager admitted that the IDT meeting never occurred, that the fall was not investigated, and that she falsified the IDT note while aware that surveyors were reviewing the incident, despite facility expectations and RN job descriptions requiring accurate, truthful clinical documentation.
A cognitively impaired resident with advanced dementia, known to express pain through agitation, aggression, leaning forward, and attempts to stand, was kept in a wheelchair near the nurses’ station for several hours and repeatedly tried to get up before sustaining a fall with a C1 fracture. Staff did not perform a pain assessment when the resident was agitated and repeatedly attempting to stand, and the LPN involved reported not knowing how to recognize the resident’s pain expressions. The resident’s pain care plans were not individualized to his non-verbal cues and relied on a 0–10 numeric self-rating scale, even though the resident was unable to use such a scale, leading to questionable pain documentation and staff being unaware of how the resident expressed pain.
The facility failed to complete an accurate, building-specific facility assessment to determine needed resources and staffing for its resident population, including many residents with dementia or cognitive impairment. The written assessment left the behavioral and cognitive acuity fields blank, did not describe how supervision needs for cognitively impaired residents would be met, and contained generic staffing ratios that did not account for 12‑hour shifts or explain how staffing levels were determined for each unit. Leadership interviews revealed that about half of the residents had dementia or cognitive impairment, there was no formal acuity measure in use, and nursing staff levels were insufficient to meet supervision needs, with reports that residents were getting hurt. The DSD, interim DON, and administrator all acknowledged that the assessment did not clearly address dementia care, supervision requirements, or a method to determine acuity for staffing.
A unit manager falsified an IDT fall note for a resident with dementia, impulse disorder, anxiety, and a history of falls who experienced an unwitnessed fall in front of the nurse's station. The note stated that an IDT including rehab, social services, DSD, infection preventionist, QA nurse, and MDS coordinator met, reviewed the incident and contributing factors, and implemented interventions such as 30-minute rounding and floor mats. In interviews, the DSD reported no such IDT meeting occurred and that she had not attended, and the unit manager admitted the IDT meeting never happened, the fall was not investigated, and the documentation was falsified. The ADM and interim DON stated documentation must be true and accurate, and the existing alert charting policy lacked guidance on accurate and truthful documentation.
The facility’s QAPI committee did not effectively identify or address lack of supervision and inadequate nurse staffing as contributing factors to multiple resident falls, most of which were unwitnessed. A UM assigned as the QA nurse for falls tracking recognized a pattern of falls related to insufficient supervision, including for two residents, but reported that staffing was only discussed generally and was not treated as a QAPI action item or performance improvement project. Although an undated QAPI plan referenced CNA and LVN staffing instability and its impact on short staffing and resident care, the interim DON and administrator acknowledged that falls, supervision, and staffing were not made a focused part of QAPI, and that supervision needs were not met when many residents were left near nurses’ stations while staff were occupied with other tasks.
A resident with Parkinson's disease and moderate cognitive deficits, requiring maximum assistance with transfers, was left unattended on the toilet and experienced an unwitnessed fall into the bathtub. Staff failed to perform immediate post-fall neuro-checks and delayed notifying the physician and responsible party, resulting in a delayed diagnosis of multiple rib fractures. Facility policy requiring prompt post-fall assessment and notification was not followed.
A resident with Parkinson's disease, cognitive deficits, and lower extremity impairments, who required maximum assistance with toilet transfers, was left unattended in the bathroom after being assisted onto the toilet. While alone, the resident lost balance and fell into the bathtub, sustaining multiple rib fractures and pain. Staff interviews and facility documentation confirmed the resident was not provided the necessary supervision, contrary to the facility's fall management policy.
The facility failed to discard eight loaves of bread past their use by date, as observed during a kitchen tour with the Dietary Supervisor. The DS and Registered Dietitian confirmed that the bread should have been discarded to prevent potential food contamination and food-borne illness among the 72 residents.
A resident's privacy was violated when their vital signs record, containing personal and medical information, was left unattended at a nursing station. Interviews with facility staff confirmed that this was against the facility's policy on maintaining the confidentiality of medical records.
Two residents with communication difficulties were not provided with necessary communication tools, despite their care plans indicating the need for such tools due to conditions like dementia and aphasia. Observations showed these residents struggling to communicate, and both a licensed nurse and the DON acknowledged the absence of communication aids, which were essential for the residents to convey their needs.
A resident with dementia and atrial fibrillation was observed with a purplish discoloration on the elbow, which was not documented or monitored as required by the facility's policy. The Director of Nursing confirmed that the nursing staff failed to meet the expectation of documenting and monitoring skin changes, as outlined in the facility's Skin and Wound Management policy.
A facility failed to ensure a resident's gastric tube (GT) was free from air bubbles, which could lead to complications. The resident, with dysphagia and other medical conditions, had an air bubble in the GT line, observed during an interview with the Director of Staff Development. The Director of Nursing confirmed that licensed nurses should check GTs before, during, and after feeding to prevent air bubbles, as per facility policy.
A resident with heart and respiratory failure requiring continuous oxygen was found with an empty oxygen tank, which was not replaced in a timely manner. The facility's staff failed to check the oxygen tank every two hours as required, leading to a deficiency in providing safe respiratory care.
A facility failed to ensure that staff followed physician orders and had adequate competency in using low air loss mattresses and wound vacuum therapy. Observations revealed that a nurse was unaware of the manufacturer's guidelines for mattress settings, affecting four residents. Additionally, two residents received wound vacuum therapy with incomplete physician orders, which were not clarified. The DON admitted to a lack of awareness and training regarding the equipment, posing a potential risk to resident care.
The facility failed to provide a registered nurse (RN) for at least eight hours a day, affecting 99 residents. This deficiency was identified through a review of the CMS Payroll Based Journal, which showed no RN hours on multiple days. Interviews with the Director of Staff Development and the Director of Nursing confirmed the lack of RN coverage, which is required by the facility's policy.
Two residents with diabetes did not receive their Humalog insulin as ordered by their physicians, with administration occurring after meals instead of before. This deviation from the prescribed schedule was confirmed by an LPN and acknowledged by the DON, highlighting a failure to adhere to the facility's medication administration policy.
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate. Two residents received medications without proper identification verification by LNs, contrary to facility policy. The residents had various medical conditions, and the LNs admitted to not using two identifiers, despite being familiar with the residents. The DON emphasized the importance of following identification procedures to prevent errors.
The facility failed to maintain infection control procedures, with a leaking water reservoir tank covered in mold and a resident's urinary catheter bag touching the floor. The water tank was not regularly inspected, leading to mold growth, while the catheter bag's improper positioning risked contamination. These lapses were acknowledged by the facility's staff.
The facility was found non-compliant with regulations limiting resident room capacity to four residents. Observations revealed two rooms could house five residents each, and seven rooms could house six residents each. No quality of care or life concerns were noted, and a waiver from CMS allowing this arrangement was recommended for renewal.
A facility failed to provide the required minimum space of 80 square feet per resident in a multiple resident room. The room measured 479 square feet and housed six residents, resulting in only 79.83 square feet per resident. Despite this, residents did not express complaints, and no quality of care or life concerns were observed. A continuance of a previously granted CMS waiver was recommended.
A resident with a left above-the-knee amputation experienced a skin tear during a transfer when a Restorative Nursing Assistant (RNA) used a Hoyer lift alone, against the facility's policy requiring two-person assistance. The resident, dependent on maximum assistance for transfers, reported discomfort during the procedure. Interviews with staff confirmed the policy and the need for two-person assistance to ensure safety.
A resident with dementia exhibited inappropriate behavior towards female residents, such as touching their arms or thighs. Despite documentation of these incidents, the care plan was not updated to guide staff on managing the behavior. Interviews with staff revealed attempts to redirect the resident, but no formal care plan was in place, contrary to facility policy.
A resident with severe cognitive impairment and diabetes experienced severe hypoglycemia and hospitalization due to the facility's failure to monitor blood sugar levels and notify the physician of low blood sugar episodes. The resident was on multiple diabetic medications, and the facility did not follow its hypoglycemia protocol, leading to the resident becoming unresponsive and being diagnosed with sulfonylurea-induced hypoglycemia and a urinary tract infection.
A resident with a history of hemiplegia, hemiparesis, cerebral infarction, and diabetes mellitus experienced a worsening of a pressure ulcer from stage II to stage III due to the facility's failure to develop a care plan and properly reposition the resident. Observations and interviews confirmed the lack of documentation and adherence to repositioning protocols.
The facility failed to provide haircuts for residents, including one with dementia, over a 10-month period due to delays in vetting a new barber/beautician after a change of ownership. This impacted residents' dignity and self-esteem, as confirmed by the Activity Director and Director of Nursing.
The facility failed to develop an effective QAPI program, leading to several deficiencies including a non-functional call light system, lack of Covid immunizations, worsening pressure ulcers, no haircuts for 10 months, unidentified hypoglycemia in a diabetic resident, and failure to perform GDRs for antipsychotic medications. The Medical Director also did not provide oversight regarding GDRs.
The facility's QAPI program failed to address several critical issues, including a non-functional call light system, lack of COVID-19 immunizations, worsening pressure ulcers, and inadequate diabetes management. The QAPI committee had not met formally since October 2023, and no Performance Improvement Plans were developed, placing all residents at risk for accidents, infections, and worsening physical and psychosocial harm.
The facility's QAPI committee failed to meet at least quarterly, with the last meeting held on 10/10/23. The Administrator acknowledged that while problems were identified, formal QA meetings were not conducted, potentially affecting resident safety and care quality.
The facility failed to develop and implement individualized care plans for three residents, including one with End Stage Renal Disease requiring dialysis, another with Diabetes Mellitus, and a third with dementia and a left humerus fracture. Interviews and record reviews confirmed the absence of necessary care plans, leading to potential risks in their care and health status.
The facility failed to consistently evaluate fall risks and conduct care conferences after falls for two residents, leading to repeated falls without new preventive measures. Additionally, the facility did not complete quarterly safety smoking evaluations for five residents, posing a risk for smoking-related injuries.
The facility failed to document non-pharmaceutical interventions or GDR for three residents reviewed for unnecessary medication. Recommendations for GDR were not acted upon, and non-pharmaceutical interventions were not attempted or documented. Missed psychotropic meetings led to a failure to monitor behaviors and follow up on medication regimen reviews.
The facility's Governing Body failed to ensure effective oversight and necessary resources for resident care services, potentially affecting the quality of care. A record review and interviews revealed that critical aspects of resident care were not adequately reviewed or discussed, and communication among facility leadership was still developing.
The facility's Medical Director failed to oversee psychotropic drug use and Gradual Dose Reductions (GDR) for 38 residents, resulting in no monthly evaluations or GDR attempts for nine months. The MD admitted that the facility had fallen behind in conducting necessary reviews and that psychotropic medications were not a primary focus since the facility changed ownership.
The facility failed to offer, re-offer, or administer COVID-19 vaccinations to 39 residents, including newly admitted and sampled residents, since reopening. Interviews and record reviews revealed that the facility had not conducted a vaccination clinic since March 2023, and the vaccination tracking log inaccurately documented refusals. The DON confirmed that the facility did not follow its policy to evaluate and offer vaccinations upon admission, potentially placing residents, staff, and visitors at risk for COVID-19 infection.
The facility failed to recognize and honor a resident's Advanced Directive indicating 'Do not resuscitate, no life supporting measures.' The resident's wishes were not communicated or documented properly, leading to a discrepancy between the physician's order and the resident's Advanced Directive. Interviews revealed that staff were unaware of the Advanced Directive in the electronic chart.
The facility failed to maintain a safe and homelike environment, with issues including peeling paint on a resident room door and exposed nails and drywall in a shower room. The DM was unaware of the peeling paint due to a lack of a maintenance log, and the ADM acknowledged the potential risks. The DM also admitted to not following up with an outside company to complete wall repairs in the shower room.
The facility failed to capture and transmit accurate MDS information to CMS for two residents, leading to potential impacts on their care. One resident's schizophrenia diagnosis was not recorded, and another resident's resuscitative wishes were not accurately documented.
The facility failed to complete a PASARR Level 2 after a resident was newly diagnosed with schizophrenia. The MDS nurse missed the diagnosis, and the Admission MDS did not include it, leading to a lack of appropriate state assessment and services for the resident.
The facility failed to update and revise care plans for two residents, one with dementia and a history of falls, and another with dementia and protein-calorie malnutrition. The care plans did not include necessary interventions, such as fall prevention measures and specific nutrition interventions, potentially impacting the residents' health status.
The facility failed to follow up on dietary recommendations for a resident with dementia and protein-calorie malnutrition, leading to significant weight loss. Despite observations of poor food intake and recommendations from the dietitian, the necessary dietary changes were not implemented, and the physician was not informed.
The facility failed to date and time enteral tube feedings for two residents, leading to potential complications and risk of infections. Observations revealed unlabeled feeding and flush bags, and staff confirmed the lack of labeling, which could result in bacterial growth and infection. The facility's policy required labeling, but no recent training had been provided to staff.
A facility failed to identify and manage the pain of a resident with dementia and a left humerus fracture. The resident, who had moderately impaired cognitive skills, was observed yelling and waving her hands in bed. Despite complaints of pain during transfers and showers, no pain medications were administered recently. The MDS nurse was unaware of the pain complaints, and no pain assessments were found. The DON confirmed that the resident's pain and pain triggers were not identified, contrary to the facility's pain management policy.
The facility failed to ensure a physician managed a resident's care, leading to unaddressed significant weight loss despite recommendations from the RD. The physician was unaware of the resident's weight loss and dietary needs due to poor communication.
The facility failed to ensure staff competency in managing diabetes, leading to a critical low blood sugar episode for a resident who was subsequently hospitalized. Interviews revealed that staff had not received diabetes management training while employed at the facility, relying solely on their nursing school education. The Director of Nursing confirmed that the last annual skills check was conducted in September 2022, and that competency training should be completed upon hire and annually.
The facility failed to post daily nurse staffing information for five consecutive days due to the absence of the DSD, who expected team leaders to handle the posting. Both the DSD and DON acknowledged the importance of this requirement, which is mandated by the facility's policy.
The facility failed to properly label and store medications in three instances: an unsecured medication cup at a nurse's station, an undated Breztri Aerosphere inhaler in a medication cart, and a lack of temperature monitoring for the Automated Drug Dispensing System (ADDS).
Failure to Provide Individualized Fall Prevention and Adequate Supervision for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that cognitively impaired residents with a history of repeated falls were free from accident hazards and received adequate, individualized supervision to prevent falls with injury. Two residents with advanced dementia and documented fall histories were repeatedly placed in front of the nurses’ station for “supervision” without any assessment or care plan interventions that clearly defined their supervision needs. For one resident with severe cognitive impairment, impulsivity, and total dependence for transfers, fall care plans were generic, focused on environmental safety and post-fall monitoring, and did not address his inability to use the call light, his frequent attempts to stand unassisted, or the need for continuous, close supervision when agitated. Staff interviews confirmed that this resident could not follow directions, was highly impulsive, frequently tried to get out of bed or his wheelchair, and required someone to sit right next to him when he was awake and agitated. On the night of this resident’s serious fall, video footage showed he was brought out of his room around midnight and placed in his wheelchair in front of the nurses’ station, where he remained for several hours. Between approximately 5:01 A.M. and 5:29 A.M., he repeatedly leaned forward and attempted to stand from his wheelchair multiple times. A nurse was seen intermittently assisting him back into the chair but then leaving his side to perform other tasks, despite his immediate, repeated attempts to get up again. At the time of the final fall, the nurse had her back turned inside the nurses’ station, and the resident stood and fell forward out of camera view, resulting in two forehead lacerations and a C1 cervical fracture. Staff, including the unit manager and the nurse caring for him, acknowledged that he needed 1:1 supervision when repeatedly trying to stand, that there was not enough staff to provide this level of supervision, and that residents placed at the nurses’ station were not continuously supervised during busy times such as early morning hours. The facility also failed to adequately assess and care plan supervision needs for a second cognitively impaired resident with Alzheimer’s disease, difficulty walking, and multiple prior falls, including unwitnessed falls in her room and in common areas. Her fall risk evaluation was not updated in a timely manner, and her fall care plan remained vague, with non-specific interventions such as “initiate fall precautions” and “determine resident’s ability to transfer,” without clearly defined supervision frequency or responsibilities. She was placed in front of the nurses’ station when up in her wheelchair, yet she sustained an unwitnessed fall from her wheelchair in that location while nearby nurses were occupied giving report, resulting in a lumbar compression fracture. She later experienced additional unwitnessed falls in front of the nurses’ station and in the dining room while unsupervised. CNAs and a unit manager reported that this resident was confused, very independent, had poor safety awareness, often got up without asking for help, and required monitoring at least every 15 minutes, but they also stated there was not enough staff to provide that level of supervision. In both residents’ cases, interdisciplinary team (IDT) fall notes and evaluations did not identify the root causes of the falls or generate relevant, individualized preventive interventions. For the first resident, an IDT note documenting a post-fall review was acknowledged by the authoring unit manager to be falsified, not actually reflecting a real meeting or investigation, and the recommended interventions (such as 30-minute rounding) were not pertinent to the circumstances of the fall and did not meet his supervision needs. For both residents, IDT documentation after serious falls lacked analysis of why the falls occurred and did not include specific, actionable strategies to prevent recurrence. Fall risk evaluations were inaccurate or outdated, and suggested interventions (such as sensor alarms or toileting programs) were either not used by the facility or not appropriate for the residents’ conditions. Staff interviews consistently described a pattern of insufficient staffing to supervise high-risk residents, especially during peak workload times, resulting in residents with known high fall risk being left without adequate, individualized supervision despite being placed near the nurses’ station. The combination of non-individualized fall care plans, inaccurate or untimely fall risk assessments, lack of thorough root-cause investigations, and acknowledged inability to staff to residents’ supervision needs led directly to repeated, unwitnessed falls with serious injuries for these two cognitively impaired residents. The facility’s practice of placing high-risk residents in front of the nurses’ station without assigning dedicated staff or defining specific supervision parameters did not prevent falls and, in these cases, allowed residents with known impulsivity and poor safety awareness to stand and fall without timely staff intervention.
Insufficient Staffing and Supervision for High Fall-Risk, Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff and adequate supervision for residents at high risk for falls, particularly those with dementia and impaired safety awareness, even when they were placed in front of the nurses’ station for closer monitoring. One resident with advanced dementia, severe cognitive impairment (BIMS score of 3/15), a history of multiple prior falls, impulsive behavior, inability to follow directions, and inability to use the call light purposefully was repeatedly brought out of his room at night and placed in a wheelchair in front of the nurses’ station for supervision. Video footage showed that from midnight to 5 a.m. he remained in front of the nurses’ station, and beginning around 5 a.m. he made repeated attempts to stand from his wheelchair. The nurse intermittently intervened to sit him back down but then left his side to perform other tasks, during which time he immediately tried to get up again. At one point, with the nurse’s back turned while she was occupied with other duties inside the nurses’ station, the resident stood and fell forward out of camera view, sustaining two forehead lacerations and later being diagnosed with a C1 cervical fracture. Staff, including the LPN, DSD, and unit manager, acknowledged that this resident could not follow instructions, could not use the call light meaningfully, was highly impulsive, and required someone next to him when agitated and attempting to stand, but his fall care plans did not include individualized or specific supervision interventions. Another resident with Alzheimer’s disease, dementia, difficulty walking, muscle weakness, and a BIMS score of 5/15 had a long history of falls, including multiple unwitnessed falls in her room and in common areas. She was cognitively impaired, frail, and had poor safety awareness, often attempting to transfer or change positions without asking for help despite being able to follow directions and use the call light. Progress notes documented several falls, including an unwitnessed fall in front of the nurses’ station while staff were giving report, during which she fell from her wheelchair and later was found to have sustained a compression fracture of the lumbar spine (L1–L2). Staff interviews indicated that this resident needed monitoring at least every 15 minutes because she would get up without asking for assistance, but CNAs reported they were responsible for large assignments, had multiple residents needing showers and mechanical lifts, and did not have enough staff to provide that level of supervision. The resident’s care plan after an unwitnessed fall included an intervention to place her at the nurses’ station when up in a wheelchair, yet she continued to have unwitnessed falls, including one in front of the nurses’ station and another in the dining room. The facility also failed to provide consistent supervision for multiple cognitively impaired, high fall-risk residents who were lined up in wheelchairs in front of the nurses’ stations on two units. On Unit B, with a census of 33 residents and only one nurse and two CNAs on duty, several residents with dementia, Alzheimer’s disease, and prior falls were observed seated in front of the nurses’ station in the early morning hours. The lights at the nurses’ station were off, the computers were off, and no staff were present within visual range; the nurse was down the hall at the medication cart and could not see the residents, while CNAs were in and out of rooms performing care. Staff stated that these residents were placed there for close supervision and that some were known fall risks, but also reported there were not enough staff to provide close supervision. On Unit A, with 40 residents and one nurse with three CNAs on night shift, multiple residents with dementia, Alzheimer’s disease, Parkinson’s disease, prior fractures, and histories of falls were similarly placed in front of the nurses’ station for supervision. Staff, including CNAs and a unit manager, reported that residents placed at the nurses’ station required frequent monitoring (e.g., every 15 minutes) due to confusion, restlessness, and poor safety awareness, but acknowledged that staffing levels were insufficient to meet these supervision needs for all residents requiring increased monitoring. Across these events, the facility’s own fall logs showed 46 falls between 1/1/26 and 3/30/26, 34 of which were unwitnessed, including unwitnessed falls for residents specifically identified as high risk and placed at the nurses’ station for supervision. Staff interviews repeatedly described being too busy with medication passes, showers, changing briefs, and shift report to continuously observe residents seated at the nurses’ station. Nurses and CNAs stated there was no designated staff member assigned solely to supervise these residents, and that requests for additional staff were met with statements that no staff were available. Unit managers and the DSD acknowledged that there had been no assessment to determine specific supervision needs for at least one high-risk resident and that care plans lacked individualized supervision interventions, despite staff recognizing that certain residents required 1:1 or very frequent monitoring when awake and attempting to stand. Family and physician interviews further described the residents’ conditions and needs at the time of the incidents. Family members of the resident with the C1 fracture reported that he was confused, had back pain, became agitated at night, had weak legs, and had fallen many times, and that staff had told them the facility was short staffed. The resident’s physician confirmed he had very advanced dementia, could not articulate pain, and had sustained a neck fracture from the fall. For the second resident, hospital documentation confirmed the lumbar compression fracture following a fall from her wheelchair. Facility leadership and staff acknowledged that residents were placed in front of the nurses’ station specifically for close supervision due to their cognitive impairment and fall risk, yet observations and interviews showed that consistent, adequate supervision was not provided because nursing staff were occupied with other tasks and staffing levels were insufficient to meet the supervision needs of all high-risk residents placed there.
Failure to Post and Maintain Actual Daily Nurse Staffing Hours
Penalty
Summary
The deficiency involves the facility’s failure to post daily nurse staffing information that reflected the actual hours worked by staff responsible for resident care, and the failure to have actual hours readily available upon request. During an interview and record review, the Director of Staffing Development (DSD) acknowledged that the Daily Nurse Staffing Information posted in the lobby for a reviewed date contained only projected hours, not actual hours worked, and stated she did not know the actual hours worked. When nursing hours for two specific dates were requested and later provided, the DSD again confirmed these were projected hours and explained that an outside management company handled the actual hours, leaving the facility without access to that information. The DSD further stated the facility did not know whether it was meeting State-required nursing hours. In a separate telephone interview, the interim DON stated the facility should have access to actual nursing hours worked, that these hours should be posted per regulation, and that actual hours should be readily available when requested. In another interview with the administrator, attended by unit managers and the DSD, the administrator also stated the facility should have access to and post actual nursing hours worked. Review of the facility’s undated policy on Nursing Department – Staffing, Scheduling & Postings showed that the facility’s own policy required posting, on a daily basis at the beginning of each shift, the total number and actual hours worked by RNs, LPNs/LVNs, and CNAs directly responsible for resident care per shift, making nurse staffing data available to the public upon request, and maintaining the posted data for at least 18 months. These requirements were not being met as described in the interviews and record reviews.
Failure to Individualize and Revise Fall Care Plans After Repeated Falls
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise individualized fall care plans that addressed resident-specific supervision needs after multiple falls for two cognitively impaired residents. For the first resident, who had dementia, an impulse disorder, anxiety, a history of falls, and a very low BIMS score indicating significant cognitive impairment, the MDS showed the resident required maximal assistance to stand and was totally dependent on staff for transfers. Progress notes documented numerous falls over an extended period, including witnessed and unwitnessed falls in the hallway, in front of the nurses’ station, and in the resident’s room, some resulting in lacerations and hospital transfers. Despite this pattern, the written fall care plans remained generic and did not address the resident’s need for close supervision. The initial fall care plan for this resident, initiated in early December, listed broad interventions such as assessing fall risk on admission and with changes in condition, assisting with ambulation and transfers per therapy recommendations, determining transfer ability, using floor mats, alerting the provider after a fall, performing neuro and bleeding evaluations per protocol, implementing fall precautions per facility protocol, and maintaining a clutter-free room. The Director of Staff Development (DSD) stated that this care plan contained nothing individualized for fall prevention and did not address the resident’s supervision needs, despite the resident’s inability to follow directions, lack of situational awareness, and inability to use the call light purposefully. A subsequent care plan created after a witnessed fall in mid-February focused on post-fall monitoring, including medication review, monitoring and reporting signs and symptoms such as pain and changes in mental status, and performing neuro checks for 72 hours, but again did not include preventive or supervision-related interventions. After another fall in late March that resulted in lacerations and a possible shoulder injury, the fall care plan was revised to include contacting hospice MD if authorized to send the resident to the hospital, monitoring and reporting signs and symptoms for 72 hours, performing neuro checks, and sending the resident to the ER for further evaluation. The DSD stated these interventions did not prevent further falls and that the care plans should have been revised with individualized interventions based on the resident’s needs, including his higher need for supervision that led to his placement in front of the nurses’ station. A unit manager (UM 2) confirmed that the interdisciplinary team was supposed to meet after each fall to investigate the cause and develop relevant interventions, but acknowledged that the resident’s care plans did not address his supervision needs and that no assessment had been done to determine those needs. For the second resident, who had Alzheimer’s disease, unspecified dementia, difficulty walking, muscle weakness, and a BIMS score indicating cognitive impairment, the MDS showed the resident required moderate assistance for transfers. Progress notes documented multiple falls over time, including assisted and unassisted falls in the bathroom, in the resident’s room, by the commode, in the hallway, in front of the nurses’ station, and in the dining room, with some falls resulting in head and facial bleeding, a compression fracture, and hospital transfers. A unit manager (UM 1) stated that this resident wanted to remain independent but was confused, frail, and required staff to monitor her every 15 minutes to ensure she was not trying to get up on her own. UM 1 also noted that the last fall risk evaluation before a January fall had been done many months earlier and that the resident should have been reassessed for fall risk with her quarterly MDS assessments. UM 1 reviewed the resident’s fall risk care plan, which had been created shortly after an early fall and revised later, and stated it was vague. The care plan included an intervention stating, “If resident is a fall risk, initiate fall precautions,” but UM 1 indicated the resident’s fall risk should have been clearly determined earlier with specific fall precautions. Another intervention, “Determine resident’s ability to transfer,” was also identified as something that should have been established long before. An intervention to “increase rounding frequency,” initiated after the January fall, lacked clarity about who was responsible and did not specify the intended 15-minute interval. Another intervention stated that when the resident was up in a wheelchair, she would be placed at the nursing station, yet the resident still experienced an unwitnessed fall in front of the nurses’ station and another fall in the dining room afterward. An IDT note following the January fall documented the team’s meeting and confirmation of a compression fracture but did not include any discussion of the root cause of the fall or recommendations to prevent further falls. The interim DON, who had recently started in the role, reported that falls for residents, including these two, had not been thoroughly investigated to determine their causes. She stated that IDT documentation she reviewed only described the falls without identifying root causes, and emphasized that without determining how the falls happened, relevant interventions could not be added to care plans to prevent further incidents. The medical records director confirmed that the facility did not have a policy for care plan development or revision. As a result of these actions and inactions, the facility failed to revise fall care plans with resident-specific interventions that addressed supervision needs for the two residents after falls occurred, creating the potential for further falls as stated in the report.
Falsified IDT Fall Documentation by RN/Unit Manager
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality when a registered nurse/unit manager (UM 2) falsified an interdisciplinary team (IDT) fall note for one resident. The resident had dementia, an impulse disorder, an anxiety disorder, and a history of falls, and had experienced an unwitnessed fall in front of the nurse’s station. An IDT Progress Note-Falls dated 4/13/26 documented that an IDT, including the director of rehabilitation, social services director, director of staff development (DSD), infection preventionist, quality assurance nurse, and MDS coordinator, met to review the incident, contributing factors, and the resident’s care plan, and that interventions such as 30-minute rounding and floor mats would be implemented or reinforced. During interviews and record reviews, the DSD stated that an IDT meeting was supposed to be conducted after a resident fall but confirmed that no IDT was conducted to investigate this resident’s fall on 3/26/26. The DSD also stated she was not aware of, and did not attend, any IDT meeting on 4/13/26, despite being listed as a participant in the IDT note. UM 2 later acknowledged that the IDT meeting for this resident’s fall did not occur, that the fall was not investigated, and that she authored the IDT note knowing the IDT members were too busy to meet and that surveyors were reviewing the fall. UM 2 admitted the IDT note was falsified and agreed that IDT documentation should be factual and accurate. The administrator and interim DON both stated that falsifying resident documentation was unacceptable and that clinical documentation should be true and accurate, while the RN job description required accurate, timely, and concise recording of care information in accordance with established standards of care, policies, and procedures.
Failure to Individualize Pain Assessment and Management for a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate, and individualized pain management for a cognitively impaired resident with advanced dementia and other mental health diagnoses. The resident had a BIMS score of 3/15, a physician-documented lack of capacity to understand and make decisions, and was known to be unable to clearly communicate needs, typically only saying “mama” and sometimes yes or no. Staff and the resident’s family reported that the resident became agitated, aggressive, restless, and attempted to stand or move when in pain, including grabbing at his back and leaning forward in his wheelchair. Despite these known behaviors and the facility’s own pain management policy requiring assessment based on non-verbal cues when a resident cannot verbalize pain intensity, the resident’s pain care plan and assessments were not individualized to his cognitive status or pain expressions. On the night in question, the resident was brought out of his room around midnight and placed in a wheelchair in front of the nurses’ station, where he remained for approximately five hours. Video footage showed the resident repeatedly leaning forward and attempting to stand from his wheelchair between 5:01 A.M. and 5:29 A.M. Staff, including a licensed nurse, intermittently assisted him back into the wheelchair but then left his side to perform other tasks, during which he immediately attempted to get up again. At 5:29 A.M., with the nurse’s back turned while she was in the nurses’ station, the resident stood up from his wheelchair and fell forward out of camera view. Progress notes documented that this was an unwitnessed fall in the hallway resulting in two forehead lacerations and a possible right shoulder injury, and the resident was later found to have a C1 fracture and was transferred for neurosurgical evaluation. Interviews and record review showed that the resident’s pain was not assessed when he was agitated and repeatedly trying to get up, and that staff did not consistently recognize his non-verbal pain cues. The unit manager stated that when the resident kept trying to stand up that night, the nurse should have assessed him for pain and acknowledged that the record showed no pain assessment when he presented as agitated. The licensed nurse involved stated she could not tell if the resident was in pain after the fall and did not know how to recognize his expression of pain. The resident’s family member reported that the resident had lower back pain, would try to stand and move to alleviate it, and became agitated and aggressive when in pain, and believed staff did not know when he was in pain. The medical doctor confirmed the resident had very advanced dementia, could not articulate his pain, and could have been experiencing discomfort from sitting in his wheelchair for five hours, and stated the nurse should have assessed for pain when the resident kept trying to get up. Further record review revealed that the resident’s pain assessments were documented using a 0–10 numeric self-rating scale, with the MAR indicating that the resident had “self-rated” his pain as zero on numerous days and as high as 10/10 on several occasions. The unit manager and interim DON both stated the resident was not capable of using a numeric pain scale, and the unit manager questioned the validity of all such documented self-ratings, including zeros, stating “he can’t use it.” The resident’s pain care plans for “Resident at Risk for Pain” and “Acute Pain/Chronic Pain” did not identify how he expressed pain, did not include relevant ways to assess his pain, and were not individualized to his non-verbal behaviors, instead relying on administration of pain medication based on a self-rating scale. As a result, nursing staff were unaware of how the resident expressed pain, and his pain management was not provided according to acceptable standards of practice.
Failure to Conduct Accurate Facility Assessment for Dementia Care and Staffing Acuity
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that accurately reflected the needs of its resident population, particularly residents with dementia or cognitive impairment, and the resources required to care for them. The written facility assessment dated 10/15/25 acknowledged that the facility accepted residents with Alzheimer’s disease and dementia and referenced behavioral symptoms and cognitive performance in its acuity table, but the corresponding number/average range of residents was left blank. Although the assessment’s services section referenced mental health and behavior needs, including care of individuals with cognitive impairment, it did not identify how the facility would meet the supervision needs of these residents. The assessment’s staffing plan section listed generic staffing numbers and ratios for licensed nurses (RN, LVN) and nurse aides (CNA, RNA), but it did not explain how these numbers were determined, did not reflect that nursing staff worked 12‑hour shifts, and did not describe a method for determining resident acuity to support sufficient staffing. The tables contained placeholders such as “1:x LN ratio” and “1:x ratio days/evenings/nights” without clear, building‑specific calculations or justification. The assessment also failed to describe how individual staff assignments were determined and reviewed to ensure coordination and continuity of care across units, and it did not specify the staffing needs on each resident unit for residents requiring increased supervision. Interviews with facility leadership confirmed that the written assessment did not match actual resident needs or staffing practices. At the time of survey, the census was 73 residents, with 27 residents documented as having a dementia diagnosis. The DSD, who was covering staffing, stated that approximately half of the residents had dementia or cognitive impairment and required more supervision, that there was no measure of resident acuity being done, and that the facility lacked sufficient nursing staff to meet supervision needs, resulting in residents getting hurt. The DSD further stated that the staffing numbers in the assessment were not personalized to the building, were inaccurate, and that she did not understand their origin. The interim DON and the administrator both acknowledged that staffing was a problem, that resident acuity should have been assessed and clearly reflected in the facility assessment, and that the assessment should have identified and assessed resident supervision needs, which had not occurred.
Falsified IDT Fall Documentation by Unit Manager
Penalty
Summary
The deficiency involves falsified clinical documentation related to a fall investigation and interdisciplinary team (IDT) review for a resident with dementia, impulse disorder, anxiety disorder, a history of falling, and other diagnoses. The resident had an unwitnessed fall in front of the nurse's station. An IDT Progress Note-Falls was entered, stating that an IDT composed of the director of rehabilitation, social services director, director of staff development (DSD), infection preventionist, quality assurance nurse, and MDS coordinator met to review the incident, contributing factors, fall risk status, environment, and current care plan, and that interventions such as 30-minute rounding and floor mats would be implemented or reinforced. During interviews and record review, the DSD stated that an IDT meeting was supposed to be conducted after a resident fell, but there was no IDT conducted to investigate this resident's fall. The DSD further stated she was not aware of and did not attend the IDT meeting documented in the note. UM 2, the unit manager and author of the IDT note, stated that the IDT team normally met after each fall to investigate and plan appropriate interventions, but in this case the IDT meeting for the resident's fall did not occur and the fall was not investigated. UM 2 acknowledged that she wrote the IDT note indicating that the meeting had occurred, that the IDT members were too busy to conduct the meeting, that she was aware surveyors were looking into the fall and that the IDT needed to be done, and that the IDT note was falsified. The administrator and interim DON both stated that clinical documentation, including IDT notes, should be true and accurate, and the facility’s Alert Charting Documentation policy did not provide guidance on documenting accurately and truthfully in residents’ clinical records.
QAPI Committee Failed to Address Staffing and Supervision as Causes of Resident Falls
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee effectively identified and addressed lack of supervision and inadequate nurse staffing as contributing factors to resident falls. A facility list showed 46 resident falls between 1/1/26 and 3/30/26, of which 34 were unwitnessed, meaning staff were not present to see what happened. The unit manager (UM) assigned as the QA nurse for falls tracking since January 2026 stated she had identified a pattern of falls related to lack of supervision, including in the unwitnessed falls of Resident 1 and Resident 2. She reported that while staffing issues were discussed during monthly QA meetings, staffing had not been identified as contributing to the lack of supervision, was not included as part of the QAPI committee’s work, and was not an action item or performance improvement project, despite her belief that falls, supervision, and staffing should have been thoroughly examined by the QA/QAPI committee. During a joint interview and record review, another UM stated the QA/QAPI committee met for a quarterly meeting and that staffing had been part of QAPI, presenting an undated QAPI Performance Improvement Plan on CNA and LVN staffing stability that described staffing instability, call-offs, workers’ compensation absences, extended hiring processes, and new-hire turnover, with an impact of short staffing, increased workload, and risk to resident care and regulatory compliance. However, the interim DON stated that resident falls, supervision, and staffing should have been addressed and made a focused part of QAPI. The administrator acknowledged that residents’ supervision needs should have been met, that many residents were observed in front of the nurses’ stations while staff were occupied with other tasks, and that he had not realized staffing was such an issue. He confirmed that although staffing was discussed at every QA/QAPI meeting, it was not actively worked on by the QAPI committee, and that while falls were a QA/QAPI action item, supervision and staffing had not been identified as contributing factors, contrary to the facility’s QAPI policy requiring identification of issues, planning and implementation of actions, and monitoring and follow-up.
Failure to Follow Post-Fall Protocols Resulting in Delayed Diagnosis of Injuries
Penalty
Summary
The facility failed to provide necessary care and services according to its fall policies and procedures for a resident who experienced an unwitnessed fall. The resident, who had a history of Parkinson's disease, moderate cognitive deficits, and required maximum assistance with transfers, was left unattended on the toilet and subsequently fell into the bathtub. After the fall, the resident experienced rib pain and was found by staff in the bathtub, but immediate post-fall assessments, including neurological checks, were not performed as required by facility policy. Interviews and record reviews revealed that staff did not initiate post-fall neuro-checks or notify the resident's physician and responsible party immediately after the incident. Instead, these actions were delayed until the following day, despite the resident exhibiting pain and bruising in the rib area. The facility's fall management policy required neurological checks for 72 hours following an unwitnessed fall or suspected head injury, as well as prompt notification of the physician and responsible party, but these procedures were not followed. The delay in post-fall care and assessment resulted in a delayed diagnosis of multiple rib fractures for the resident. Staff interviews indicated confusion or misinformation regarding post-fall protocols, with one nurse stating that the previous DON had advised that post-fall procedures were not necessary in such cases. The current DON confirmed that the expected protocol was not followed, which contributed to the delay in identifying and treating the resident's injuries.
Failure to Provide Adequate Supervision Results in Resident Fall and Injury
Penalty
Summary
A resident with a history of Parkinson's disease, moderate cognitive deficits, and lower extremity impairments was admitted to the facility and assessed as high risk for falls. The resident required maximum assistance with toilet transfers. On the day of the incident, the resident was assisted to the toilet by nursing staff and then left alone for privacy at the resident's request. While unattended, the resident lost balance and fell into the bathtub, sustaining multiple rib fractures and experiencing pain. The fall was unwitnessed, and the resident waited approximately five minutes before staff responded to her calls for help. Interviews with staff confirmed that the resident was left unattended in the bathroom despite her need for significant assistance with transfers and her high fall risk status. The facility's own investigation and care plan documentation indicated that the resident should not have been left alone due to her impairments and risk factors. The facility's fall management policy required providing a safe environment and supervision to prevent accidents, which was not followed in this instance, resulting in harm to the resident.
Failure to Discard Expired Bread
Penalty
Summary
The facility failed to store foods under sanitary conditions when eight loaves of bread with use by labels were not discarded. During a kitchen tour with the Dietary Supervisor (DS), eight loaves of bread were observed with a use by date of 1/6/25, which had not been discarded. The DS acknowledged that the bread should have been discarded either a day before or on the use by date. The Registered Dietitian (RD) confirmed that bread with use by labels should be thrown away on or before the use by date. This oversight had the potential to cause food contamination and spread food-borne illness among the 72 residents of the facility.
Violation of Resident Privacy Due to Unattended Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical records, resulting in a violation of privacy for Resident 28. The resident, who was re-admitted to the facility with diagnoses including Acute Prostatitis, a local skin infection, and a urinary tract infection, had their vital signs record left unattended on the counter of nursing station one. This record contained sensitive information such as the resident's name, room number, and various vital signs, making it accessible to anyone passing by. Interviews with the Infection Preventionist/Registered Nurse (IP/RN) and the Director of Nursing (DON) confirmed that the vital signs record is considered part of the medical records and should be kept secure and confidential. Both acknowledged that leaving the record unattended violated the resident's right to privacy. The facility's policy on the disclosure of protected health information (PHI) mandates that medical records be kept secure and shielded from public view, which was not adhered to in this instance.
Failure to Provide Communication Tools for Residents with Communication Difficulties
Penalty
Summary
The facility failed to provide necessary communication tools for two residents, Resident 13 and Resident 36, who had documented communication difficulties. Resident 13, diagnosed with dementia, hemiplegia, and urinary retention, was observed struggling to communicate using incomprehensible words, sign language, and head nods. Despite the care plan indicating the need for alternative communication tools due to communication problems related to dementia and a cerebrovascular accident, Resident 13 was not provided with any such tools. This was confirmed by both a licensed nurse and the Director of Nursing, who acknowledged the absence of a communication tool for Resident 13. Similarly, Resident 36, diagnosed with aphasia and hemiplegia, was observed having difficulty communicating and using sign language and gestures. The care plan for Resident 36 also specified the need for alternative communication tools due to expressive and receptive aphasia. However, like Resident 13, Resident 36 was not provided with any communication tools. This deficiency was acknowledged by the same licensed nurse and the Director of Nursing, who confirmed the necessity of a communication tool for Resident 36 to convey their needs effectively.
Failure to Document and Monitor Skin Discoloration
Penalty
Summary
The facility failed to provide necessary care for a resident, identified as Resident 54, by not assessing and documenting skin discoloration as required. Resident 54, who was admitted with diagnoses including dementia and atrial fibrillation, was observed to have a purplish discoloration on the right side of the right elbow during an initial tour. Despite the presence of this discoloration, there was no documentation on the resident's treatment activity record (TAR) to monitor the condition, as confirmed by the Director of Staff Development (DSD). The Director of Nursing (DON) stated that it was expected for nursing staff to monitor and document any skin changes on the residents' TAR. However, this expectation was not met in the case of Resident 54, as the skin discoloration was neither documented nor monitored. The facility's policy on Skin and Wound Management required new non-pressure ulcers, bruises, and lacerations to be documented on the 24 Hour Log and an incident report to be completed by a Licensed Nurse, which was not adhered to in this instance.
Failure to Ensure Gastric Tube Free from Air Bubbles
Penalty
Summary
The facility failed to ensure that a gastric tube (GT) was free from potential complications for a resident with dysphagia, cerebral infarction, and hemiplegia. During an observation and interview with the Director of Staff Development (DSD), it was noted that the resident's GT had an air bubble in the line, which could lead to abdominal discomfort. The DSD acknowledged that the licensed nurse responsible for preparing the GT should have primed the tube to prevent air from entering. Additionally, the resident and their GT should have been checked every two hours to ensure the feeding was free from air. The Director of Nursing (DON) confirmed that licensed nurses are expected to check residents' GTs before, during, and after the infusion of GT feeding to ensure they are free from air bubbles. The facility's policy on enteral feedings, dated September 7, 2023, also indicated that pump tubing should be primed. The failure to adhere to these protocols resulted in a deficiency, as the presence of air in the GT line had the potential to compromise the resident's health condition.
Failure to Timely Replace Oxygen Cylinder for Resident
Penalty
Summary
The facility failed to replace an oxygen cylinder for Resident 61 in a timely manner, which had the potential to affect her wellbeing. Resident 61 was admitted with diagnoses including heart failure and respiratory failure with hypoxia, requiring continuous oxygen at 2 liters per minute via nasal cannula for shortness of breath. During an observation and interview, Resident 61 reported that no oxygen was coming out of her cannula, and her oxygen tank was found to be empty. Certified Nursing Assistant (CNA) 6 confirmed the tank was empty and needed replacement. The Director of Staff Development stated that Resident 61's oxygen tank should have been checked every two hours for fullness and functionality. The Director of Nursing expected the nursing staff to provide adequate oxygenation and stated that the oxygen tank should have been replaced timely to prevent shortness of breath. The facility's policy on oxygen therapy, dated November 2017, indicated that oxygen should be administered per physician orders. However, the failure to replace the oxygen tank as required led to a deficiency in providing safe and appropriate respiratory care for Resident 61.
Deficiency in Staff Competency and Adherence to Physician Orders
Penalty
Summary
The facility failed to ensure that licensed nurses followed physician orders and had adequate competency in providing care to residents using low air loss mattresses and wound vacuum therapy. Observations and interviews revealed that the licensed nurse (LN) was unaware of the manufacturer's guidelines for setting low air loss mattresses according to residents' weights. This lack of knowledge was evident in the care of four residents who were observed with incorrect mattress settings. The Director of Nursing (DON) admitted to not being aware of the different types of low air loss mattresses and pumps used in the facility and acknowledged the absence of staff training and competency in this area. Additionally, the facility did not ensure that physician orders for wound vacuum therapy were clear and complete. Two residents were receiving wound vacuum therapy with a negative pressure setting of 125 mm/Hg, despite the physician orders being incomplete and lacking specific pressure settings. The LN admitted that the orders should have been clarified with the physician but were not. The DON confirmed that the orders were incomplete and should have been clarified to ensure they were carried out correctly for patient safety. The facility's policies and procedures were not followed, as evidenced by the lack of adherence to the manufacturer's guidelines for low air loss mattresses and the failure to confirm that physician orders were clear, complete, and accurate. This deficiency in staff competency and adherence to procedures posed a potential risk to the residents' care and well-being.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide a registered nurse (RN) for at least eight hours a day, affecting 99 residents. This deficiency was identified through a review of the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) for the fourth quarter of 2024, which showed no RN hours on four or more days. During an interview and record review with the Director of Staff Development (DSD), it was confirmed that there was no RN coverage for at least eight hours a day on specific dates in July, August, and September 2024. The Director of Nursing (DON) also acknowledged that an RN should have been present in the facility for at least eight hours per day to provide necessary and appropriate care. The facility's policy requires at least one RN or Licensed Vocational Nurse to be present at all times, in addition to the Director of Nursing Services (DONS).
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents, which posed a potential risk to their well-being. Resident 2, diagnosed with hemiplegia, diabetes, and a pressure ulcer, had specific physician orders for Humalog (Insulin Lispro) to be administered subcutaneously before meals and at bedtime, based on a sliding scale for blood sugar levels. However, the Medication Administration Record (MAR) indicated that the blood sugar checks and insulin administration were not conducted before scheduled meals and were not within one hour of the scheduled medication administration times on multiple occasions. Licensed Nurse 1 confirmed that the insulin was administered after meals, contrary to the physician's orders, and the Director of Nursing acknowledged the importance of timely insulin administration to prevent adverse health effects. Similarly, Resident 65, also diagnosed with hemiplegia and diabetes, had physician orders for Humalog to be administered before meals and at bedtime. The MAR showed that the insulin administration did not occur before scheduled meals and was not within the prescribed time frame on several dates. Licensed Nurse 1 and the Director of Nursing both confirmed that the physician's orders were not followed, and the insulin was administered after meals. The facility's policy and procedure for medication administration, last revised in 2012, stated that medications should be administered as directed by a licensed nurse and upon the order of a physician, which was not adhered to in these cases.
Medication Error Rate Exceeds 5% Due to Identification Failures
Penalty
Summary
The facility failed to ensure that the medication error rate during medication pass did not exceed 5 percent, resulting in an error rate of 16 percent. This was identified through observations, interviews, and record reviews. During a medication pass, a Licensed Nurse (LN) administered medications to a resident without verifying the resident's identity using two identifiers, as required by the facility's policy. The resident had a medical history that included diabetes, peripheral vascular disease, and a foot ulcer. The LN admitted to not checking the resident's identifiers, despite being familiar with the resident, and acknowledged the importance of following the identification process to ensure resident safety. Another incident involved a different resident with diagnoses including dementia, hemiplegia, and urinary retention. During a medication pass, another LN administered medication without using two identifiers to verify the resident's identity. The LN stated that she identified the resident by name and was familiar with him, but recognized the need to adhere to the policy to prevent medication errors. The Director of Nursing confirmed the importance of following the identification process to prevent errors and ensure resident safety. The facility's policy, last revised in 2012, mandates that medications must be given by the LN who prepared them and that the resident's identity must be verified before administration.
Infection Control Lapses in Water Management and Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control procedures, as evidenced by two significant observations. First, a 550-gallon water reservoir tank located outside the kitchen was found to be leaking and had a greenish-black substance, identified as mold, surrounding the opening of the faucet. The faucet was not covered, and the water inside the tank was deemed unusable. Interviews with the Infection Preventionist (IP), Maintenance Supervisor (MS), and Director of Nursing (DON) revealed that regular inspections of the water reservoir tank were not conducted, which led to the presence of mold and potential waterborne pathogens. Additionally, the facility failed to ensure proper urinary catheter care for a resident with dementia, hemiplegia, and urinary retention. The resident's urinary catheter bag was observed touching the floor while attached to their wheelchair. The DON acknowledged that the catheter bag should not touch the floor to prevent contamination and infection spread. The facility's policy on catheter care, which mandates that the catheter and collecting bag be anchored to avoid floor contact, was not adhered to in this instance.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with the regulatory requirement that resident rooms house no more than four residents. During the annual recertification survey, it was observed that two rooms had the potential to accommodate five residents each, and seven rooms could accommodate six residents each. This configuration was contrary to the standards set forth in 42 CFR section 483.70(d)(1)(i). Despite these observations, there were no noted quality of care or quality of life concerns directly related to the number of residents in the rooms. The facility had previously been granted a waiver by CMS, allowing more than four residents per room, and a continuance of this waiver was recommended, contingent upon timely renewal by CMS.
Room Size Deficiency in Multiple Resident Room
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum space of 80 square feet per resident in a multiple resident room. During the annual recertification survey, it was observed that room [ROOM NUMBER] measured 479 square feet and was intended to house six residents, resulting in an allocation of only 79.83 square feet per resident. Despite this deficiency, the five residents occupying the room did not express any complaints, and there were no observed concerns regarding their quality of care or quality of life. The facility had previously been granted a waiver from the Centers for Medicare and Medicaid Services (CMS) allowing for less than 80 square feet per resident, and a continuance of this waiver was recommended.
Inadequate Assistance During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate assistance during a transfer for a resident with a left above-the-knee amputation, resulting in a skin tear. The incident occurred when a Restorative Nursing Assistant (RNA) transferred the resident from bed to a Hoyer lift alone, contrary to the facility's policy requiring two-person assistance for such transfers. The resident, who was dependent on substantial maximum assistance for transfers due to limited physical mobility, experienced discomfort during the transfer, which was later associated with a skin tear on the amputated leg. Interviews with the RNA, Treatment Nurse (TXN), and Director of Nursing (DON) confirmed the facility's policy of requiring two-person assistance for mechanical lift transfers to ensure safety and prevent accidents. The resident's care plan and physician orders also indicated the need for two-person assistance due to partial weight-bearing status and dependency on others for mobility. The incident was reported to the department, and the resident's cognition was noted to be intact, as indicated by a BIMS score of 14 on the Minimum Data Set (MDS).
Failure to Revise Care Plan for Inappropriate Resident Behavior
Penalty
Summary
The facility failed to revise the care plan for a resident who exhibited inappropriate behavior towards female residents. The resident, diagnosed with dementia, was admitted to the facility and had a history of touching female residents on their arms or thighs, which was perceived as inappropriate by some. Despite these behaviors being documented in progress notes, the care plan was not updated to reflect these incidents or to provide guidance for staff on how to manage the behavior. Interviews with facility staff, including a CNA and an LN, revealed that the resident's behavior was known, and staff attempted to redirect him, although he sometimes became aggressive. The Director of Nursing confirmed that there was no care plan addressing the resident's behavior, which was necessary to alert staff and implement appropriate interventions. The facility's policy required care plans to be reviewed and revised to address changes in behavior, but this was not done in this case.
Failure to Monitor and Communicate Hypoglycemia in Diabetic Resident
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with diabetes, leading to severe hypoglycemia and hospitalization. Resident 51, who had severe cognitive impairment, was on multiple diabetic medications, including Glimepiride, Insulin glargine, Sitagliptin, and Pioglitazone. Despite the resident's history of low blood sugar, the facility did not monitor blood sugar levels according to standard practice, nor did they notify the resident's physician of hypoglycemic episodes. This lack of monitoring and communication resulted in the resident becoming unresponsive and being sent to the hospital, where they were diagnosed with sulfonylurea-induced hypoglycemia and a urinary tract infection. Interviews with the facility's licensed nurses, medical doctor, and pharmacy consultant revealed that Resident 51's blood sugar should have been checked at least twice daily due to the multiple diabetic medications. However, the Medication Administration Record (MAR) and progress notes showed several instances where blood sugar levels were dangerously low, and there was no documented evidence that the physician was notified or that the blood sugar was reassessed. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed these findings and acknowledged that the facility's hypoglycemia protocol was not followed. The facility's policy on hypoglycemia required immediate notification of the attending physician and close monitoring of the resident's condition, including checking blood sugar and vitals every 15 minutes until stable. However, this protocol was not adhered to, as evidenced by the lack of documentation and communication regarding Resident 51's low blood sugar episodes. The failure to follow these procedures contributed to the resident's severe hypoglycemia and subsequent hospitalization.
Failure to Prevent Worsening of Pressure Ulcer
Penalty
Summary
The facility failed to prevent the worsening of a pressure ulcer for a resident, identified as Resident 35, who was admitted with a history of hemiplegia, hemiparesis, cerebral infarction, and diabetes mellitus. Despite being at high risk for pressure ulcers and dependent on staff for bed mobility, there was no care plan developed for Resident 35's stage II pressure ulcer identified on 9/17/23. Over time, the ulcer deteriorated to a stage III pressure ulcer by 11/7/23, as documented in the resident's progress notes and change of condition assessments. Observations revealed that Resident 35 was frequently found lying upright in bed directly on her sacrum, even though a wedge pillow was available but not used. The resident was observed in this position multiple times over several days, indicating a lack of proper repositioning. Interviews with CNA 23 and LN 31 confirmed that there was no documentation or evidence that Resident 35 was turned and repositioned as required to prevent further decline of the pressure ulcer. The Director of Nursing acknowledged the lack of documentation and the failure to turn and reposition Resident 35 frequently, which contributed to the deterioration of the pressure ulcer from stage II to stage III. The facility's policy on pressure injury prevention and the lesson plan on pressure injury management both emphasized the importance of repositioning residents at least every two hours, which was not adhered to in this case.
Failure to Provide Haircuts for Residents
Penalty
Summary
The facility failed to provide haircuts for residents, including Resident 42, over a 10-month period from April 1, 2023, to February 14, 2024. Resident 42, who has dementia and requires assistance with personal hygiene, was observed with long, unkempt hair. Interviews with Resident 42's daughter and the resident himself confirmed that he preferred to keep his hair short. The Activity Director (AD) acknowledged the lack of haircut services since the facility's change of ownership in April 2023, citing delays in the hospital's vetting process for a new barber or beautician. Family members had been bringing in their own hairdressers for some residents, but those without family support had not received haircuts. The AD expressed frustration with the delay and its impact on residents' dignity and self-esteem. The Director of Nursing (DON) confirmed the issue, stating that no haircuts had been performed for a long time and acknowledging the potential negative impact on residents' self-esteem and dignity. The facility's policies on Resident Rights-Quality of Life and Resident Rights-Accommodation of Needs emphasize the importance of grooming and accommodating individual preferences, but no specific policies related to haircuts or ADLs were found. The deficiency highlights a failure to maintain residents' quality of life and dignity by not providing necessary grooming services.
Failure to Develop Effective QAPI Program
Penalty
Summary
The facility failed to develop an effective Quality Assurance Performance Improvement (QAPI) program, as the committee did not consistently track, address, and follow up on quality issues affecting the residents. Specific deficiencies included a non-functional call light system for several days, failure to offer Covid immunizations to residents, worsening of a pressure ulcer for a resident, lack of haircuts for residents over a 10-month period, unidentified hypoglycemia in a diabetic resident leading to a 10-day hospitalization, and failure to routinely perform Gradual Dose Reductions (GDRs) for residents on antipsychotic medications. Additionally, the Medical Director did not provide oversight regarding GDRs. These failures placed all residents at risk for accidents, infections, and worsening physical and psychosocial harm. During an interview, the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional Consultant (RC) acknowledged that the last QAPI meeting had been held several months prior, and although problems were identified, no formal Quality Assurance (QA) meetings were conducted to address these issues. The malfunctioning call light system was known but not reported to the California Department of Public Health (CDPH) or addressed with a safety watch. Infection control practices were reviewed, but the lack of Covid vaccines was not discussed. Pressure ulcers were part of the QAPI discussion, but no significant improvement was noted. The issue of haircuts was not escalated to the necessary level for resolution. Diabetes management and staff training were not adequately discussed, and no plan was developed for GDRs. The previous administrator had not developed a plan for these issues, and more QAPI interventions were deemed necessary by the current administration to identify and solve these problems.
Ineffective QAPI Program and Multiple Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program, as evidenced by several deficiencies that were not adequately tracked, addressed, or followed up on. The call light system was non-functional for several days, and the facility did not implement a safety watch or report the issue to the California Department of Public Health (CDPH). Infection control practices were also lacking, as COVID-19 immunizations were not offered to residents. Additionally, a resident's pressure ulcer worsened, and haircuts were not provided to residents for an 11-month period due to a lack of a necessary contract. A resident with diabetes experienced unidentified hypoglycemia for two days, resulting in a 10-day hospitalization. Furthermore, Gradual Dose Reductions (GDRs) for residents on antipsychotic medications were not routinely performed, and the Medical Director did not provide oversight for identifying problem-prone QAPI interventions. The facility's QAPI committee had not met formally since October 10, 2023, and although problems were identified, no Performance Improvement Plans were developed. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional Consultant (RC) acknowledged these issues during an interview. The DON and ADON were unaware of the lack of COVID-19 vaccines being offered, and the RC noted that pressure ulcers were discussed but not adequately addressed. The Administrator admitted that the issue of haircuts was not escalated to the necessary level for resolution, and diabetes management and staff training were not included in QAPI discussions. The previous administrator had identified GDRs as an issue but did not develop a plan to address it. Overall, the facility's failure to implement an effective QAPI program placed all residents at risk for accidents, infections, and worsening physical and psychosocial harm.
QAPI Committee Failed to Meet Quarterly
Penalty
Summary
The facility Quality Assurance Performance Improvement (QAPI) committee failed to meet at least quarterly, as required by their own QAPI plan and policy. During a record review and interview conducted on 2/20/24, it was found that the last QAPI meeting was held on 10/10/23. The Administrator admitted that although problems had been identified, the committee had not formally convened to conduct a proper QA meeting. This failure to hold regular QAPI meetings had the potential to affect the safety and quality of care provided to residents.
Failure to Develop Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents, leading to potential risks in their care and health status. Resident 14, who was admitted with End Stage Renal Disease and required dialysis, did not have a care plan addressing his dialysis needs. Interviews with LN 31, LN 35, and the DON confirmed the absence of a dialysis care plan, which was crucial for guiding healthcare staff in providing appropriate care for Resident 14's condition. This oversight was observed during multiple interviews and record reviews, highlighting a significant gap in the resident's care management. Resident 51, diagnosed with Diabetes Mellitus, had a care plan that lacked resident-specific interventions for monitoring abnormal blood sugar levels. Interviews with LN 31 and the ADON revealed that the care plan was not individualized to address the resident's specific needs. Additionally, Resident 7, who had dementia and a left humerus fracture, did not have a care plan for pain management despite frequent complaints of pain during transfers and other activities. Interviews with CNA 22, LN 22, and MDSN 1, along with observations, confirmed the absence of a pain care plan, which was necessary to address the resident's pain triggers and ensure comfort. The DON acknowledged the need for a comprehensive, person-centered care plan to manage Resident 7's pain effectively.
Failure to Evaluate Fall Risks and Conduct Smoking Assessments
Penalty
Summary
The facility failed to consistently evaluate Fall Risk Assessments and conduct Care Conferences after each resident fall, which led to multiple falls for two residents. Resident 19, who had severe dementia, experienced several falls without proper post-fall evaluations or new interventions being implemented. Despite being at high risk for falls, the resident's fall risk score was inconsistently documented, and no new measures were taken to prevent future falls after each incident. Similarly, Resident 49, who had hemiplegia following a stroke, experienced numerous falls without appropriate post-fall evaluations or care conferences. The resident's fall risk score was often lowered instead of increased, and no new interventions were added to the care plan to prevent future falls. The facility's staff, including CNAs and LNs, were aware of the procedures but failed to follow them consistently, leading to repeated falls and inadequate preventive measures. Additionally, the facility did not complete continuous quarterly safety smoking evaluations for five residents who smoked. These residents had various conditions that impaired their ability to smoke safely, yet no follow-up evaluations were conducted to reassess their smoking safety. The facility's policy required quarterly assessments, but this was not adhered to, posing a risk for smoking-related injuries.
Failure to Document Non-Pharmaceutical Interventions and Gradual Dose Reductions
Penalty
Summary
The facility failed to document non-pharmaceutical interventions or gradual dose reductions (GDR) for three residents reviewed for unnecessary medication review. Resident 3, who was readmitted with diagnoses including dementia and schizoaffective disorder, had no documented evidence that the physician agreed or disagreed with the consulting pharmacist's recommendation for a GDR. Additionally, no non-pharmaceutical interventions were attempted or documented for Resident 3, and an injection of Ativan was administered without prior documentation of behavior or non-pharmaceutical interventions. Resident 42, who was readmitted with dementia and behavior disturbances, also had no documented evidence that the physician agreed or disagreed with the consulting pharmacist's recommendation for a GDR. The facility had not conducted psychotropic medication care conferences since merging with a hospital, leading to a lack of evaluation of the necessity of the medications and potential dose reductions. Interviews with staff confirmed that non-pharmaceutical interventions were not attempted or documented for Resident 42. Resident 10, who was admitted with a history of depression, had a recommendation from a psychiatrist to decrease the dosage of Sertraline, but there was no evidence that this recommendation was followed. The Director of Nursing confirmed that the missed psychotropic meetings led to a failure to monitor behaviors and follow up on medication regimen reviews. The facility's policy on behavior and psychotropic drug management was not adhered to, resulting in a break in the system for evaluating the necessity of psychotropic medications.
Governing Body Fails to Ensure Effective Oversight and Resources for Resident Care
Penalty
Summary
The facility's Governing Body failed to ensure effective oversight and necessary resources for resident care services, which had the potential to affect the quality of care provided to residents. During a record review, it was found that the Governing Body did not adequately review or discuss critical aspects of resident care, such as pressure ulcers, falls with significant injury, equipment malfunctions, and performance improvement projects (PIPs). The facility's policies indicated that the Governing Body should be involved in these areas, but there was no evidence of effective implementation or oversight. An interview with the facility's Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional Consultant (RC) revealed that the Governing Body met monthly, but communication and coordination among the facility's leadership were still developing. The facility's policies and procedures, including the Organization Performance Improvement Plan, emphasized the importance of the Governing Body's role in quality oversight and regulatory compliance. However, the lack of effective oversight and resource allocation by the Governing Body was evident, as they failed to ensure the highest practical physical, mental, and psychosocial well-being of each resident.
Failure to Oversee Psychotropic Drug Use and Gradual Dose Reductions
Penalty
Summary
The facility's Medical Director (MD 1) failed to oversee care area concerns related to psychotropic drug use and Gradual Dose Reductions (GDR) for 38 out of 83 residents currently receiving psychotropic medications. As a result, these residents did not have their psychotropic medications evaluated monthly, and their care needs were not addressed in a timely manner. There were no psychotropic care conferences, and no GDRs were attempted for nine months. This lapse in oversight could potentially be harmful to residents, as the medications have side effects that need regular monitoring and adjustment. During an interview, MD 1 admitted that the management team, which he led, was expected to meet monthly to evaluate nonpharmacological interventions, determine the amount of behaviors exhibited, and assess the number of side effects displayed. However, MD 1 acknowledged that the facility had fallen behind in conducting these reviews and GDRs. The facility's Medical Directorship Agreement and the Medical Director Duties outlined the responsibilities of the MD, including the supervision and oversight of health services and the review of residents' conditions and medication regimens. Despite these outlined duties, the MD admitted that since the facility changed ownership, psychotropic medications were not a primary focus, leading to the deficiency.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer, re-offer, or administer COVID-19 vaccinations to a total of 39 residents, including five sampled residents and 34 newly admitted residents after the facility reopened. This failure was identified through interviews and record reviews, which revealed that the facility had not conducted a COVID-19 vaccination clinic since March 2023. The facility's vaccination tracking log inaccurately documented refusals for residents who were never offered the vaccine. Resident 56, for example, stated he had not been offered the vaccine upon admission or during his stay and expressed a desire to receive it. The facility's Infection Control Surveillance indicated that 50 residents tested positive for COVID-19 in January 2024, including 20 newly admitted residents. Interviews with the ADON, IPN 22, IPN 23, and the DON confirmed that the facility had not offered COVID-19 vaccinations to residents upon readmission or new admission since reopening in September 2023. The facility's policy required that residents be evaluated for vaccination status upon admission and offered the vaccine within seven days if not previously vaccinated. The DON acknowledged that the facility should have offered vaccinations to both readmitted and newly admitted residents. The failure to follow the facility's COVID-19 Vaccination Program policy potentially placed residents, staff, and visitors at risk for COVID-19 infection.
Failure to Recognize and Honor Resident's Advanced Directive
Penalty
Summary
The facility was unaware of an Advanced Directive related to a resident's wishes for resuscitative efforts. Resident 36, who was admitted with Parkinson's disease, had an Advanced Directive indicating 'Do not resuscitate, no life supporting measures' that was scanned into the electronic record. However, the physician's order listed CPR, and there was no documented evidence of a POLST in the clinical record. During a multidisciplinary care conference, the section for resuscitative wishes was left blank and unmarked. Interviews with the resident and staff revealed that the resident had expressed her wishes to not have CPR performed, but these wishes were not communicated or documented properly within the facility. The ADON was unaware of the Advanced Directive in the electronic chart and acknowledged the potential for the resident's wishes to not be followed. The DON stated that all resident wishes for Advanced Directives and POLST should be recognized and honored. The facility's policies on Advanced Directives and POLST were not adhered to, leading to the deficiency.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, homelike environment in two specific instances. First, an exterior resident room door for one of 25 rooms had peeling paint. This room housed four residents, two of whom were cognitively impaired. The Director of Maintenance (DM) was unaware of the issue as he did not keep a maintenance log and only addressed repairs as they were reported. The Administrator (ADM) acknowledged that the peeling paint could be ingested by confused residents and agreed that the door needed repair. Second, the exterior shower room door frame in Station B had multiple holes, exposed drywall, and two protruding nails. The DM stated that an outside company had installed new shower door frames but had not returned to complete the wall repairs. The DM had not followed up with the company and admitted that the exposed nails could pose a risk of injury. The ADM also confirmed that the condition of the shower wall did not present a homelike environment and could potentially injure residents and staff.
Failure to Capture Accurate MDS Information
Penalty
Summary
The facility failed to capture and transmit accurate MDS information to CMS for two residents, which had the potential to affect the care and services provided to them. Resident 3 was readmitted with diagnoses including dementia and schizoaffective disorder. However, the Admission MDS did not identify the diagnosis of schizophrenia, despite it being listed in the Admission Record. The MDSN acknowledged the oversight and stated that CMS did not have the correct information on Resident 3's current health status due to this error. Resident 36 was admitted with a diagnosis of Parkinson's disease and had conflicting information regarding resuscitative wishes. The physician's order indicated CPR, while the Advanced Directive scanned into the electronic record indicated Do Not Resuscitate. The quarterly MDS did not capture any choices for life-sustaining treatment, leaving all sections blank. The MDSN admitted that the POLST and Advanced Directive were not captured, resulting in CMS and the facility being unaware of the resident's resuscitative wishes. The DON emphasized the importance of accurate assessments for all residents to ensure the facility and CMS are aware of their resuscitative preferences.
Failure to Complete PASARR Level 2 for Resident with New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure a Pre-admission Screening and Resident Review Level 2 (PASARR) was completed after a new diagnosis of schizophrenia was made for a resident. The resident was readmitted to the facility with diagnoses including dementia and schizoaffective disorder. However, the Admission MDS did not include the diagnosis of schizophrenia, and the original PASARR Level 1 was completed as negative. The MDS nurse admitted to missing the schizophrenia diagnosis, which should have triggered a new PASARR Level 1 and potentially a Level 2 assessment by the state to ensure appropriate placement and services for the resident. The Director of Nursing confirmed that MDS assessments need to be accurate on admission to ensure residents receive the necessary care and services. The facility's policy mandates a new PASARR Level 1 screening for residents experiencing a significant change in condition, and if indicated, a Level 2 screening should be completed by the state. The facility could not provide documented proof that a PASARR Level 2 was completed or that they followed up with the state to ensure its completion.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise individualized care plans for two residents, which had the potential to impact their health status and prevent further decline. Resident 19, who was admitted with dementia and had a history of falls, was observed with bolsters on his mattress to prevent falls. However, the care plan did not include the use of these bolsters. The ADON confirmed that the care plan should have been updated to include the bolsters to ensure staff were aware of the fall prevention measures in place for Resident 19. Resident 21, also admitted with dementia and protein-calorie malnutrition, was observed consuming less than half of his meals during multiple observations. The care plan for weight loss, initiated earlier, referenced a nutrition progress note rather than documenting specific interventions. The RD and ADON both acknowledged that the care plan should have included specific nutrition interventions to address Resident 21's weight loss. The lack of an updated care plan could result in further weight loss, as it failed to communicate the necessary interdisciplinary interventions for the resident's nutrition needs.
Failure to Follow Up on Dietary Recommendations for Resident
Penalty
Summary
The facility failed to follow up on a recommendation for diet changes related to weight loss for Resident 21, who was admitted with diagnoses including dementia and protein-calorie malnutrition. Observations showed that Resident 21 consumed less than half of the food provided during meals and refused nutritional supplements. The Minimum Data Set indicated significant weight loss, and the resident was on a carbohydrate-controlled diet with nutritional supplements prescribed three times daily. Despite recommendations from the dietitian to liberalize the diet and reduce supplements, these changes were not implemented, and the physician was not informed of the resident's weight loss or dietary needs. Interviews with the dietitian, Assistant Director of Nursing (ADON), and the physician revealed a lack of communication and follow-through on the recommended dietary changes. The dietitian was unaware of the previous recommendations, and the ADON could not explain why the recommendations were not acted upon. The physician confirmed that he had not been contacted about the resident's weight loss or dietary recommendations and had not ordered any recent labs to assess nutritional status. The facility's policy on nutritional status evaluation was not followed, leading to a failure to address the resident's significant weight loss and nutritional needs.
Failure to Label Enteral Tube Feedings
Penalty
Summary
The facility failed to date and time enteral tube feedings for two residents, leading to potential complications and risk of infections. Resident 49, who was admitted with hemiplegia and moderate protein-calorie malnutrition, was observed with an enteral pump and feeding bags that were not labeled with the date and time. The Licensed Nurse (LN) confirmed that the bags were not labeled, which could lead to bacterial growth and infection. The Assistant Director of Nursing (ADON) emphasized the importance of labeling to prevent bacteria growth and ensure safety. Resident 81, who was readmitted with a stroke, dysphagia, and moderate protein-calorie malnutrition, was also observed with unlabeled tube feeding and water flush bags. The LN stated that the previous nurse had not written the start time and date, making it impossible to confirm if the resident received the nutrition as ordered. The Director of Nursing (DON) reiterated the expectation that all nurses should label the start and end times for tube feedings to prevent infection and ensure proper nutrition. The facility's policy on enteral feeding required labeling the formula container and tubing with the date and time. However, the Director of Staff Development (DSD) could not locate any documentation of tube feeding training or in-services provided to the LNs in the past two years. This lack of training contributed to the failure to follow the facility's policy, leading to the observed deficiencies.
Failure to Identify and Manage Resident's Pain
Penalty
Summary
The facility failed to identify and manage the source of pain for a resident with a history of dementia and a left humerus fracture. The resident, who had moderately impaired cognitive skills, was observed yelling and waving her hands in bed. A CNA indicated that the resident yelled when she wanted something, such as being repositioned for comfort. An LN confirmed that the resident complained of pain during transfers and showers but had not been administered any pain medications recently, despite having an order for Tylenol as needed. The LN suggested that pre-medicating the resident before the Restorative Nursing Assistant (RNA) program would be beneficial. Further investigation revealed that the MDS nurse was unaware of the resident's pain complaints during transfers and movement of her extremities. The MDS nurse acknowledged that pain assessments should be conducted on admission, every three months, and when a change in condition is identified, but no pain assessments were found for the resident. The DON confirmed that pain should be evaluated and addressed using indicators such as body language, facial expressions, and mood, but the resident's pain and pain triggers were not identified. The facility's pain management policy indicated that the interdisciplinary team should review and update the care plan for pain management, but this was not done for the resident.
Failure to Manage Resident's Nutritional Care
Penalty
Summary
The facility failed to ensure that the physician supervised and managed the care of a resident (Resident 21) who was admitted with diagnoses including dementia, protein-calorie malnutrition, and diabetes. Observations revealed that Resident 21 consumed less than half of the food provided during meals and refused nutritional supplements. Despite significant weight loss documented by the Registered Dietitian (RD), recommendations to liberalize the diet and reduce supplement fatigue were not implemented. The physician and nurse practitioner did not document any concerns regarding weight loss or poor intake in their progress notes, and the physician was unaware of the RD's recommendations. The facility's policy on nutritional status evaluation was not followed, as the RD's recommendations were not communicated to or acted upon by the physician. Interviews with the RD and Assistant Director of Nursing (ADON) confirmed that the recommended dietary changes were not made, and the physician stated he was not informed about the weight loss or dietary recommendations. This lack of communication and follow-through had the potential to exacerbate Resident 21's weight loss and overall well-being.
Failure to Ensure Staff Competency in Diabetes Management
Penalty
Summary
The facility failed to ensure that staff were competent in managing residents with diabetes, as evidenced by the case of Resident 51. Resident 51, who was admitted with a diagnosis of diabetes, experienced a critical low blood sugar episode and was sent to the hospital. Interviews with multiple licensed nurses (LNs) revealed that they had not received any diabetes management training while employed at the facility, relying solely on their nursing school education. This lack of ongoing training and competency assessment contributed to the failure in managing Resident 51's diabetes effectively, as evidenced by the absence of documented blood sugar checks in the Medication Administration Record (MAR) and the failure to follow the facility's low blood sugar protocol properly. The Director of Nursing (DON) confirmed that the last annual skills check, which included diabetes management, was conducted in September 2022, and that competency training should be completed upon hire and annually thereafter. The facility's policy on staff competency assessment, dated March 17, 2022, mandates that competency assessments be performed upon hire during the employee's 90-day employment period and annually. However, the interviews and record reviews indicated that this policy was not adequately followed, as staff members had not received the necessary training and education on diabetes management while employed at the facility. This deficiency in staff training and competency assessment had the potential to negatively affect Resident 51's health and well-being, as demonstrated by the critical low blood sugar episode that led to hospitalization.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the nurse staffing data was posted and readily accessible to residents and the public, and to accurately document the total number and actual hours worked by the nursing staff. During an initial tour, it was observed that the posted staffing data was outdated by five days. The Director of Staff Development (DSD) admitted that the staff posting had been missed for five consecutive days due to her absence from work, and she had expected team leaders to handle the posting in her absence. The Director of Nursing (DON) also acknowledged the importance of having the staff posting displayed publicly. A review of the facility's policy confirmed that nurse staffing data is required to be posted daily at the beginning of each shift.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to label and store medications properly in three instances. First, a medication cup with two Tylenol pills was left unsecured and unmonitored at a nurse's station, within reach of residents, staff, and visitors. This was acknowledged by a licensed nurse who admitted the medication was meant for a co-worker. The Director of Nursing (DON) confirmed that medications should not be left unattended due to safety concerns. Second, a Breztri Aerosphere inhaler was found in a medication cart without a date indicating when the foil pouch was opened, contrary to the instructions on the packaging. The licensed nurse admitted that without the date, it was impossible to know if the medication was still effective. The DON reiterated that medications must be stored according to instructions to ensure their efficacy. Third, the Automated Drug Dispensing System (ADDS) was not being monitored for temperature controls. The Assistant Director of Nursing (ADON) and the Pharmacy Consultant (PC) both confirmed that the temperature of the area where the ADDS was located was not being monitored, which is necessary to ensure the safety and efficacy of the medications stored within it. The Director of Maintenance also confirmed that temperatures were not taken in the nurse's station where the ADDS was located.
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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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