San Juan Hills Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Juan Capistrano, California.
- Location
- 31741 Rancho Viejo Road, San Juan Capistrano, California 92675
- CMS Provider Number
- 555763
- Inspections on file
- 23
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at San Juan Hills Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and no decision-making capacity was prescribed multiple psychotropic medications, including Depakote, mirtazapine, Seroquel, and PRN olanzapine. The informed consent forms signed by the resident’s responsible party were incomplete or inaccurate, with missing drug categories and durations, incorrect documentation of off-label use, and side effects listed under the wrong drug classification. Facility leadership and clinical staff acknowledged that these forms should have been fully and accurately completed so the responsible party could understand the risks, benefits, and purposes of the medications before consenting.
A resident with a physician's order to hold antihypertensive medication for SBP below 110 mmHg experienced multiple low blood pressure readings, including values as low as 83/57 mmHg. Despite these findings, there was no documentation that the physician was notified of the change in condition, as required by facility policy. Staff interviews confirmed the lack of notification and awareness of the policy requirements.
A resident at risk for constipation did not receive timely as-needed bowel management interventions as ordered by the physician, despite ongoing monitoring that showed no bowel movement for several days. Nursing staff delayed administration of prescribed laxatives and other interventions, resulting in the resident developing abdominal distention, nausea, and vomiting, and ultimately requiring transfer to an acute hospital where a small bowel obstruction was diagnosed.
A resident with severe cognitive impairment experienced multiple episodes of nausea, vomiting, diarrhea, and increased weakness, but the facility did not develop or update a care plan to address these changes in condition. Staff confirmed that a care plan should have been created, but none was found in the medical record.
A resident's care plan addressing constipation was not updated despite ongoing symptoms such as no bowel movement, abdominal distention, and nausea. The care plan interventions remained unchanged even after the resident's condition worsened, resulting in the need for hospital transfer. Facility staff confirmed the care plan was not revised as required by policy.
A resident with diabetes experienced a low blood sugar event, but staff failed to document a Change of Condition or notify the resident's representative as required. Additionally, vital signs were recorded as taken after the resident had already been discharged. These actions resulted in incomplete and inaccurate medical records, as confirmed by both the LVN and DON during interviews.
The facility's kitchens were found to have multiple sanitation and food safety deficiencies, including improper food storage, lack of hair restraints, and unsanitary practices. Observations included gnats, rust, and dirty equipment, as well as improper temperature control of food items. These issues indicate a failure to adhere to professional standards and food safety regulations.
The facility failed to ensure safe self-administration of medications for two residents. One resident had supplements and medications at her bedside without an assessment or physician's order, despite cognitive impairment. Another resident had eye drops at her bedside without authorization for self-administration. Staff confirmed the lack of necessary documentation and acknowledged the deficiencies.
The facility did not address concerns from resident council meetings or notify two residents about the outcomes of their grievances. Issues included staff noise, inadequate lighting, meal requests, and call button response times. Interviews confirmed the lack of follow-through and documentation, despite facility policies requiring timely investigation and resolution.
A facility failed to refer a resident with a mental disorder for a PASARR Level II evaluation, as required by their policy. The resident's PASARR Level 1 Screening Form incorrectly indicated no mental disorder, despite diagnoses of major depressive disorder, psychosis, and anxiety, and a prescription for sertraline. Interviews with the MDS Coordinator and DON confirmed the error, posing a risk for inadequate services and assessment.
The facility failed to ensure a safe environment for two residents who smoked. One resident was not assessed for smoking safety, and their smoking materials were found unsupervised. Another resident's smoking paraphernalia was left unsupervised, and they sometimes smoked without staff present. The designated smoking area lacked necessary safety measures, violating the facility's smoking policy.
The facility failed to implement bladder training for a resident and did not develop a toileting care plan for another, risking loss of bladder control. One resident, who was cognitively intact, was not provided with the ordered bladder retraining program, while another, who was continent, was placed in a diaper against her wishes and without a care plan. Staff interviews revealed a lack of awareness and documentation regarding these programs.
The facility failed to ensure clear physician's orders for oxygen administration for two residents, as the orders did not specify whether the oxygen was to be administered continuously or as needed. This lack of clarity was confirmed by the MDS Coordinator and the DON, potentially affecting the residents' respiratory health.
The facility failed to ensure proper pharmaceutical services, including inaccurate accounting of controlled medications for a resident, lack of signatures on pharmacy delivery slips, and improper documentation of medication disposal. These issues posed a risk of drug diversion and highlighted lapses in medication management processes.
A facility failed to accurately perform orthostatic blood pressure monitoring for a resident on antipsychotic medication. The physician's order required monitoring in three positions to check for orthostatic hypotension, but the MAR showed identical readings for all positions, indicating incorrect monitoring. The DON confirmed the inaccuracy, which could lead to adverse complications and incorrect data for medication adjustment.
A facility's medication error rate exceeded the acceptable threshold, with a rate of 7.14%. An LVN failed to administer medications as ordered for two residents. One resident did not receive instructions to chew a calcium carbonate tablet, and another received Effexor XR without food, contrary to physician orders. These errors were confirmed during observations and interviews.
The facility failed to ensure proper medication and supply storage, as expired medications were found in medication carts, and medications were improperly mixed in storage areas. Feeding formulas were stored without temperature monitoring, and over-the-counter medications lacked proper temperature logging. These issues were confirmed by the DON and staff, posing potential risks to residents' well-being.
The facility's dietary staff demonstrated a lack of competency, leading to potential risks in food and nutrition services. Observations revealed incorrect procedures for checking dishwasher temperatures and sanitizing solutions, unsanitary kitchen conditions, and improper handling of food temperatures. These issues highlight deficiencies in the oversight and responsibilities of the food service department.
The facility failed to follow menu and diet orders, leading to deficiencies in food service. Observations showed incorrect serving sizes, unsafe food temperatures, and inaccurate tray tickets. Specific incidents included a resident receiving an altered diet without documentation and another receiving inappropriate food items. These issues posed a risk to residents' nutritional adequacy.
The facility failed to serve prescribed therapeutic diets to two residents. An LVN did not verify meal trays against physician's orders, resulting in a resident receiving an incorrect diet. Additionally, a meal tray included a supplement not listed on the physician's order, confirmed by the Regional RD.
The facility failed to follow infection control practices, including hand hygiene during meal assistance and medication administration, proper storage in the laundry area, and implementing a water management program to prevent Legionella growth. Staff did not wash hands before and after assisting residents or administering medications, and personal clothing was stored with clean pillows. The facility lacked a comprehensive water management program, increasing the risk of pathogen spread.
The facility failed to monitor antibiotic use according to McGeer's criteria for two residents, leading to potential inappropriate antibiotic use. The Antibiotic Stewardship Program requires criteria to be met before prescribing antibiotics, but this was not confirmed for a resident with a cough prescribed azithromycin and another receiving Bactrim DS for pneumonia prophylaxis. Interviews with staff confirmed these findings.
The facility failed to monitor and record the freezer temperature in Medication Room A, leading to ice buildup in the freezer compartment. During an inspection, it was found that the freezer lacked a thermometer and the temperature log showed no documentation of monitoring. The facility's policy required twice-daily temperature checks, which were not followed, as confirmed by the DON.
A facility failed to conduct accurate and complete entrapment assessments for a resident using bed rails, potentially leading to serious injury or death. The Maintenance Director did not measure necessary entrapment zones for the resident's bed, as required by facility policy. This oversight was confirmed through observations, interviews, and document reviews, with the Director of Nursing verifying the findings.
The facility did not follow the puree recipe for seven residents on a puree diet, risking the conservation of nutritive value. Cook 1 added chicken broth instead of the cooking liquid to peas and used excessive thickener, contrary to the recipe. These actions were confirmed by the RD.
A resident with a right humerus fracture had blood pressure readings consistently taken from the affected arm, as documented in their medical records. Despite the resident's refusal and the LVN's acknowledgment that this practice was inappropriate, the facility failed to ensure accurate documentation and adherence to professional standards, potentially impacting the resident's care.
A resident with dementia and chronic kidney disease experienced a delay in receiving her lunch meal, waiting 40 minutes while other residents were served on time. The facility's PCC list of diets did not include her name, and staff, including the DON, could not explain the delay.
The facility did not ensure residents were informed of their rights and how to formally complain to the State Agency. During a resident council meeting, residents stated they were unaware of the contact information for the State Licensing and Certification Office. Interviews with the Activity Director and Admissions Director confirmed that this information was not provided in the admission packet, although it was posted on the consumer board.
A facility failed to follow a physician's order to discontinue a sling for a resident's right shoulder. The resident was seen wearing the sling despite the order, which was noted without a time or signature. Both the DON and DSD confirmed the order was not executed.
Incomplete and Inaccurate Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate informed consent for multiple psychotherapeutic medications prescribed to a resident who lacked decision-making capacity. Facility policies required that psychotherapeutic drug informed consent forms include the drug category, dosage, frequency, duration of use, and possible side effects and significant risks, and that PRN psychotropic medications be limited to 14 days unless reevaluated by a practitioner. For one resident with severe cognitive impairment and no capacity to make medical decisions, several informed consent forms signed by the resident’s responsible party were found to be incomplete or inaccurate. The resident had orders for Depakote, mirtazapine, Seroquel, and PRN Zyprexa Zydis for conditions including psychosis manifested by angry outbursts and striking out, and depression manifested by poor oral intake. Review of the Depakote informed consent form showed the drug category and duration were left blank, the off-label use section incorrectly indicated the drug was not being used off-label, and the probable side effects and significant risks were documented under the antipsychotic category instead of the anticonvulsant/mood stabilizer category. Nursing and pharmacy staff confirmed that Depakote is an anticonvulsant, that it was being used as an antipsychotic (off-label), and that anticonvulsants and antipsychotics have different side effect profiles. Informed consent forms for the other psychotherapeutic medications were also incomplete. The mirtazapine consent form was missing the drug category and duration. The Seroquel consent form was missing the drug category and duration. The olanzapine (Zyprexa Zydis) PRN consent form was likewise missing the drug category and duration, despite facility policy and the DON’s acknowledgment that a PRN psychotropic medication should have a 14-day duration due to the requirement for physician reevaluation. The DON stated that the expectation was for psychotherapeutic drug informed consent forms to be fully and accurately completed before being signed so that the resident or responsible party would be aware of the risks and benefits of the medications and could make an informed decision, and that incomplete or inaccurate information meant it was not informed consent. These failures posed the risk of Resident 1's Responsible Party to not understand the risks, benefits, and purpose of the medications she was consenting for the facility to administer to Resident 1.
Failure to Notify Physician of Resident's Low Blood Pressure Readings
Penalty
Summary
The facility failed to notify a resident's physician when the resident experienced multiple episodes of low blood pressure, as required by facility policy. The resident had a physician's order for Benazepril HCL to be held if systolic blood pressure (SBP) was less than 110 mmHg. Medical records showed several instances where the resident's SBP was below this threshold, including readings as low as 100/60 mmHg and, during a physical therapy session, as low as 83/57 mmHg while sitting. Despite these low readings, there was no documentation indicating that the physician was notified of the change in the resident's condition. Interviews with facility staff, including the physical therapist and the Director of Nursing (DON), confirmed awareness of the low blood pressure readings and acknowledged that the physician should have been informed. The DON also verified that facility policy required physician notification when blood pressure medication was held for three consecutive days, but there was no evidence this occurred. The deficiency was identified through interviews, medical record review, and review of facility policies and procedures.
Failure to Provide Timely Bowel Management Interventions
Penalty
Summary
The facility failed to provide necessary care and services for a resident at risk for constipation, as required by their own policies and physician orders. The resident, who had decreased mobility and was at risk for constipation due to possible medication side effects, was to have their bowel movements monitored every shift, with interventions such as prune juice, medications, and physician notification if no bowel movement occurred for more than three days. Despite these orders, the resident did not have a bowel movement from 5/30 to 6/6, and as-needed bowel management medications were not administered as ordered until six days after the last recorded bowel movement. During this period, the resident experienced abdominal distention, nausea, and vomiting. Medical record review showed that the resident was administered some scheduled bowel management medications, but the escalation to as-needed interventions, including Milk of Magnesia, Dulcolax suppository, and Fleet Enema, was delayed. Nursing staff and the DON confirmed that the as-needed medications were not provided in a timely manner according to the physician's orders. The resident's condition worsened, leading to transfer to an acute hospital, where a small bowel obstruction was diagnosed.
Failure to Update Care Plan for Change in Condition
Penalty
Summary
The facility failed to develop and implement a care plan that addressed a resident's change in condition, specifically episodes of nausea, vomiting, diarrhea, and increased generalized weakness. Despite documentation in the medical record of multiple episodes of these symptoms and the administration of non-pharmacological interventions and medication as ordered by the physician, there was no evidence that a care plan was created or updated to reflect these changes. The facility's policy requires that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and revised as residents' conditions change, but this was not followed in this case. Interviews with facility staff, including an LVN and the DON, confirmed that a care plan should have been developed in response to the resident's change in condition, and both verified that no such care plan was present in the medical record. The resident involved had severe cognitive impairment and experienced multiple documented episodes of gastrointestinal symptoms and increased weakness, yet the care plan was not updated to address these needs.
Failure to Revise Care Plan for Constipation Management
Penalty
Summary
The facility failed to revise and update the care plan for a resident who was at risk for constipation, despite ongoing changes in the resident's condition. The care plan initially addressed the risk for constipation related to decreased mobility and possible medication side effects, with interventions such as monitoring and recording bowel movements every shift, reporting abnormal stool, and notifying the physician if there was no bowel movement for more than three days. However, when the resident experienced no bowel movement for more than three days, along with symptoms of abdominal distention, nausea, and vomiting, the care plan was not updated to include additional or different interventions. Medical record review showed that the resident continued to have no bowel movement and worsening symptoms, leading to the administration of a fleet enema and eventual transfer to an acute care hospital due to persistent constipation and related symptoms. Interviews with facility staff, including an LVN and the DON, confirmed that the care plan was not revised in response to the resident's ongoing issues. The facility's policy required care plans to be updated when a resident's condition changed or when desired outcomes were not met, but this was not followed in this case.
Incomplete and Inaccurate Medical Record Documentation for Diabetic Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with diabetes, as required by their own policies and professional standards. Specifically, when the resident experienced a low blood sugar level of 58 mg/dL, there was no documentation that a Change of Condition (COC) was initiated, nor was there evidence that the resident's representative was notified of the hypoglycemic event. The facility's policies require that such events be documented, including notification of the physician and the resident's representative, but these steps were not recorded in the medical record. Both the LVN and the DON confirmed during interviews that a COC should have been initiated for blood sugar levels below 70 mg/dL, and acknowledged that the required documentation was missing. Additionally, the resident's medical record contained inaccuracies regarding the timing of vital sign documentation. Vital signs were recorded as being taken after the resident had already been discharged and transferred to an acute care hospital. The DON verified that these entries were made post-discharge, which is inconsistent with accurate and timely recordkeeping practices. The facility's policy mandates that all documentation be objective, complete, and accurate, including the date and time care was provided and the name and title of the individual documenting. These documentation failures were identified through interviews, medical record reviews, and policy reviews. The lack of proper documentation for a significant change in condition and the inaccurate recording of vital signs after discharge had the potential to impact the provision of necessary care and services due to incomplete medical record information.
Sanitation and Food Safety Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain sanitary conditions in both the satellite and main kitchens, posing a risk to food service standards. Observations included improper defrosting of juice in a hand wash sink, presence of gnats, rust on equipment, and dirty drains. Staff were observed without proper hair and beard restraints, and cutting boards were found marred and improperly stored. Food storage practices were inadequate, with items stored too close to the sprinkler system and unlabeled food in the residents' refrigerator. Further inspections revealed ongoing issues, such as staff using inappropriate methods to open equipment, improper storage of personal items near food, and continued presence of gnats. The facility also failed to maintain proper temperature control for food items, as evidenced by the cottage cheese being left unrefrigerated and served at an unsafe temperature. The Cool Down Log was incomplete, missing entries for chicken salad, and there was no documentation for the use of precooked chicken. Additionally, staff were observed engaging in unsanitary practices, such as touching masks and meal carts without hand hygiene, and placing personal items in the ice machine. These deficiencies indicate a lack of adherence to professional standards and food safety regulations, as outlined by the USDA Food Code 2022, potentially compromising resident safety.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for two residents. Resident 132 was observed with several bottles of supplements and medications at her bedside, including Biotin, coconut oil, and a hair growth medication. Despite the resident's fluctuating capacity to understand and make decisions, as indicated by a BIMS score of 9, there was no documented assessment for her ability to self-administer these medications. Additionally, there were no physician's orders authorizing self-administration, and the MDS Coordinator confirmed the absence of such orders in the resident's medical records. Similarly, Resident 14 was found with eye drops at her bedside, which she had been using for six weeks. Although there was a physician's order for the administration of artificial tears, there was no documented evidence of an assessment or physician's order permitting self-administration. LVN 3 verified the lack of documentation and confirmed that the medication should not have been kept at the bedside. The DON was informed of these findings and acknowledged the deficiencies.
Failure to Address Resident Council Concerns and Notify Residents of Outcomes
Penalty
Summary
The facility failed to address concerns raised during resident council meetings and did not notify two residents about the outcomes of their grievances. The facility's policy and procedure (P&P) required the use of a Resident Council Response Form to track issues and their resolution, with the relevant department responsible for addressing the concerns. However, documentation from the Resident Council Meeting Agenda & Notes showed unresolved issues, such as staff being loud in hallways, a resident needing more light in their room, and another resident having issues with meal requests and call button response times. There was no documentation on how these concerns were resolved or if the residents were informed of the outcomes. Interviews with the Activity Director and the Director of Nursing (DON) confirmed the lack of follow-through on the concerns raised. The Activity Director stated that the Administrator was notified of the concerns, and they were discussed in meetings with department heads, but admitted there was no follow-up. The DON verified the absence of documentation on the investigation and resolution of the concerns, as well as the lack of communication with the residents about the outcomes. The facility's P&P required concerns to be investigated within 72 hours, but this was not adhered to.
Failure to Refer Resident for PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a mental disorder was referred to the state PASARR representative for a Level II evaluation and determination screening process. This deficiency was identified during a review of the facility's Preadmission Screening & Resident Review (PASRR) policy and procedure, which mandates that the facility confirm the PASARR process was completed by the hospital before accepting a resident. In the case of Resident 16, the PASARR Level 1 Screening Form incorrectly indicated that the resident did not have a mental disorder or intellectual disability, despite the resident's admission record showing diagnoses of major depressive disorder, psychosis, and anxiety. Additionally, the resident was prescribed sertraline, an antidepressant medication, which further indicated the presence of a mental disorder. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed the error in the PASARR assessment for Resident 16. The MDS Coordinator acknowledged that the PASARR Level 1 was not accurately completed and that the resident had been receiving antidepressant medication for depression. The DON was informed of these findings and verified the deficiency. This oversight posed a risk for the resident not receiving the appropriate level of services, comprehensive assessment, intervention, and evaluation for their mental disorder.
Failure to Ensure Safe Smoking Practices for Residents
Penalty
Summary
The facility failed to provide a safe environment free from accident hazards for two residents who smoked. Resident 383 was not accurately assessed to determine if supervision or adaptive equipment was needed while smoking, nor was there a determination if they could safely store their own cigarettes or lighters. The resident's smoking materials were found unsupervised on their bedside drawer, and the facility staff were unaware of the resident's smoking habits. The medical records did not show evidence of a smoking assessment, physician's order, or a developed care plan for smoking. Resident 432's smoking paraphernalia was left unsupervised on their overbed table while they were not in the room. The resident, who was assessed as requiring supervision, sometimes smoked without staff present. The facility's care plan for Resident 432 included interventions for observing unsafe smoking practices, but these were not adequately followed. Additionally, the designated smoking area lacked readily available and accessible safety measures such as fire-retardant smoking aprons and portable fire extinguishers, as verified by the Activity Director. The facility's policy and procedure for safe smoking required that residents be evaluated for their ability to smoke safely and that safety measures be in place in designated smoking areas. However, these protocols were not followed, leading to potential fire hazards and risks of serious injuries to residents who smoked and others in the facility. The Director of Nursing verified the findings, confirming the facility's failure to adhere to its smoking policy and procedures.
Failure to Implement Bladder Training and Toileting Programs
Penalty
Summary
The facility failed to provide necessary care and services to maintain or restore bladder functions for two residents. Resident 285, who was cognitively intact, expressed a preference to use the bathroom rather than a disposable brief at night. Despite a physician's order for a bladder retraining program and a care plan intervention to follow a toileting schedule every two hours, there was no documented evidence that this program was implemented. Interviews with facility staff, including a CNA and LVN, revealed a lack of awareness and documentation regarding the bladder training program for Resident 285. Resident 436, who was continent for bladder needs, was placed in a diaper against her wishes and without a care plan addressing her specific toileting needs. Despite being able to verbalize her need to use the toilet, she was wearing a diaper, which she was allergic to. The DON confirmed that a care plan for Resident 436's toileting needs was not developed, and acknowledged that even residents in diapers could be taken to the toilet. These failures posed a risk for the residents to lose their bladder control.
Oxygen Administration Orders Lacked Clarity
Penalty
Summary
The facility failed to ensure that the physician's orders for oxygen administration for two residents were clear regarding whether the oxygen was to be administered continuously or as needed. Resident 132 was observed receiving oxygen at 2 liters per minute via nasal cannula, but the physician's order did not specify if this was to be continuous or PRN. The MDS Coordinator confirmed the lack of clarity in the physician's order during a review of the medical records. Similarly, Resident 282 was observed receiving oxygen at 3 liters per minute via nasal cannula, with the physician's order also lacking specification on whether the administration was continuous. The MDS Coordinator verified the ambiguity in the physician's order, and the DON confirmed these findings. This lack of clarity in the physician's orders had the potential to affect the respiratory health and well-being of the residents.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to ensure proper pharmaceutical services, resulting in several deficiencies. One significant issue was the inaccurate accounting and documentation of controlled medications for a resident. During an inspection, a discrepancy was found in the count of buprenorphine-naloxone tablets for a resident, with the physical count not matching the controlled medication accountability record. The Director of Nursing (DON), who was involved in the count, confirmed the discrepancy but did not initiate an investigation or provide a response when questioned about the facility's protocol for such discrepancies. Additionally, the facility did not follow proper procedures for receiving medications from the pharmacy. Several pharmacy delivery slips for controlled medications lacked signatures from the receiving nurse, indicating a failure to verify and document the receipt of medications. Furthermore, the facility did not properly document the disposal of medications, as observed in the drug disposition records, which lacked dates for when the medications were disposed of. These failures posed a risk of drug diversion and highlighted lapses in the facility's medication management processes.
Inaccurate Orthostatic Blood Pressure Monitoring for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to accurately perform orthostatic blood pressure monitoring as ordered by the physician for a resident receiving antipsychotic medication. The physician had ordered the monitoring of blood pressure in three positions (lying, sitting, and standing) once a week to check for orthostatic hypotension, which is defined as a significant decline in blood pressure upon standing. However, the medical administration record (MAR) for November showed identical blood pressure readings for all three positions on two separate occasions, indicating that the monitoring was not conducted correctly. During an interview and concurrent medical record review, the Director of Nursing (DON) confirmed that the licensed nurses did not accurately monitor the orthostatic hypotension, as evidenced by the same blood pressure readings for all positions. This inaccuracy in monitoring had the potential to result in adverse complications for the resident due to the use of antipsychotic medication and could lead to incorrect data being provided to the prescriber, affecting the adjustment of the medication dose.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 7.14%. This deficiency was identified during a survey where a licensed nurse, LVN 4, did not administer medications as per physician orders for two residents. Resident 134, who had a physician's order for Calcium Carbonate Tablet Chewable 500 mg to be chewed and swallowed for indigestion, was not instructed to chew the tablet before swallowing. This oversight occurred during a medication administration observation, where LVN 4 prepared and administered multiple medications to Resident 134 without providing the necessary instructions for the calcium carbonate tablet. Additionally, Resident 4, who had a physician's order for Effexor XR to be administered with food for depression, received the medication without food. During the medication administration observation, LVN 4 administered several medications to Resident 4, including Effexor XR, before the resident had eaten breakfast. This failure to follow the physician's order for administering the medication with food was confirmed during an interview and record review with LVN 4, who verified the findings.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage, which was identified through observations and interviews. During an inspection of Medication Cart A, expired povidone-iodine prep pads were found, and the Director of Nursing (DON) confirmed these findings. Additionally, Medication Cart B contained a mix of Zofran, acetaminophen suppositories, and bisacodyl suppositories, which was verified by an LVN. Furthermore, in Medication Room B, eye drop medications were stored alongside oral medications, and nasal sprays were stored with oral medications, which was acknowledged by an LVN. The facility also failed to properly store feeding formulas and monitor temperatures. The Central Supply Designee confirmed that enteral feeding formulas and oral supplements were stored in a room with a temperature of 75 degrees Fahrenheit, but the temperature log had not been maintained. Additionally, over-the-counter medications were stored in the Health Equipment room without a thermometer or temperature log. These deficiencies in medication and supply storage practices had the potential to negatively impact residents' well-being and lead to medication errors.
Deficiencies in Dietary Staff Competency and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that dietary staff were competent in performing their duties, which posed a risk to residents receiving appropriate food and nutrition services. During a kitchen inspection, it was observed that the Certified Dietary Manager (CDM) 1 incorrectly checked the dishwasher's temperature during the prewash cycle instead of the wash cycle, as required for proper operation. Additionally, CDM 1 was unable to demonstrate the correct procedure for checking the sanitizing solution's range, using soap and water instead of the appropriate sanitizing solution. The posted instructions indicated that the sanitizer solutions should be maintained at a range of 150-250 ppm, but the logs showed inconsistencies in the recorded ppm levels. Further observations revealed unsanitary conditions in the main kitchen, which had been previously discussed with CDM 2. During a lunch trayline observation, a container of cottage cheese was left unrefrigerated, and its temperature was not checked until prompted, revealing it was at 53 degrees, outside the acceptable range. Despite this, CDM 1 continued to serve the cottage cheese until the Registered Dietitian (RD) confirmed the temperature issue, at which point it was disposed of. These findings indicate a lack of competency and oversight in the food service department, as outlined in the duties and responsibilities of the RD and CDMs.
Deficiencies in Dietary Management and Food Service
Penalty
Summary
The facility failed to ensure that the menu and diet orders were followed, leading to several deficiencies in food service and dietary management. Observations revealed that chicken salad was not documented on the cool down log, and the kitchen staff used incorrect serving sizes, such as using a 3 oz slotted spoon instead of the required #8 scoop for noodles. Additionally, temperatures for milk and cottage cheese were not taken at the tray line, with cottage cheese being stored at an unsafe temperature of 53 degrees Fahrenheit. Plates of dessert were placed near a dirty sink, and tray tickets were inaccurate for some residents, leading to inappropriate food items being served. Specific incidents included a meal tray for a resident on a Consistent Carbohydrate Diet No Added Salt (CCHO NAS) being altered to a regular diet without proper documentation, and another resident on a liberal renal diet receiving inappropriate food items such as gravy and yogurt, which were not listed on their meal ticket. Furthermore, a resident's food tray did not include a bread roll as requested, despite the presence of butter on the tray. These findings indicate a risk of residents not receiving nutritional adequacy due to the facility's failure to adhere to prescribed diet orders and menu plans.
Failure to Serve Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were served as prescribed by the residents' physicians for two residents. During a dining room observation, an LVN was seen checking meal trays against meal tickets but not against the physician's orders. This resulted in a resident being served a no added salt, regular diet instead of the prescribed no added salt, mechanical soft diet. The LVN admitted to having memorized most of the residents' diets and acknowledged the oversight in not verifying the meal served against the physician's orders. In another instance, during a lunch trayline observation in the facility's satellite kitchen, a meal tray for a resident was found to include a Magic cup supplement that was not listed on the physician's order. The resident was supposed to be on a puree nectar thick liquid diet, but the tray ticket incorrectly included a mechanical soft meat. This discrepancy was confirmed by the Regional RD, indicating a failure to adhere to the prescribed dietary orders for the resident.
Infection Control Deficiencies in Hand Hygiene, Laundry, and Water Management
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by several observations and interviews. In one instance, an occupational therapy (OT) staff member did not perform hand hygiene before and after assisting a resident with meals. The OT staff member was observed putting on gloves without washing hands, feeding the resident, and then removing gloves to open a door for another resident. The OT staff member then put on a new pair of gloves and resumed feeding without washing hands. This was confirmed during an interview with the OT staff member, who acknowledged the lapse in hand hygiene. Additionally, the facility did not ensure proper handwashing practices during medication administration for two residents. Licensed Vocational Nurses (LVNs) were observed not performing hand hygiene before and after administering medications. Interviews with the LVNs and the Director of Nursing (DON) confirmed that handwashing should occur between administering medications to different residents, but this was not followed. The facility's policy on administering medication and hand hygiene emphasizes the importance of handwashing to prevent infection spread, yet these practices were not adhered to. The facility also failed to maintain infection control in the laundry area, where personal clothing was stored with clean pillows, as verified by the Maintenance Director. Furthermore, the facility did not have an established and implemented water management program to prevent Legionella growth. The Maintenance Director and other staff were unable to provide documentation of regular testing or specific control measures for Legionella prevention. Interviews with the Director of Staff Development/Infection Preventionist (DSD/IP) and the Administrator confirmed the lack of a comprehensive water management program, posing a risk for the spread of Legionella and other pathogens.
Failure to Monitor Antibiotic Use According to McGeer's Criteria
Penalty
Summary
The facility failed to monitor and address the use of antibiotics according to McGeer's criteria for two residents, which could lead to inappropriate antibiotic use and the development of antibiotic-resistant bacteria. The facility's Antibiotic Stewardship Program, dated June 2021, requires that antibiotics be prescribed only when clinical definitions of active infection or suspected sepsis are met, and pathogen susceptibility is confirmed. However, the Infection Preventionist (IP) did not track or review whether McGeer's criteria were met before prescribing antibiotics to Resident 7 and Resident 10. Resident 7 was admitted with a cough and was prescribed azithromycin, but the surveillance log did not confirm if McGeer's criteria were met. Similarly, Resident 10 received Bactrim DS for recurrent pneumonia prophylaxis, but the records did not show if the infection met McGeer's criteria. Interviews with the Director of Staff Development/Infection Preventionist (DSD/IP) and the Director of Nursing (DON) confirmed these findings, indicating a lapse in the facility's antibiotic stewardship practices.
Failure to Monitor Freezer Temperature and Address Ice Buildup
Penalty
Summary
The facility failed to ensure the freezer compartment inside the medication refrigerator in Medication Room A was free of ice buildup and did not monitor or record the freezer temperature in the temperature log. During an inspection and interview with the DON, it was observed that the freezer compartment had ice buildup and contained ice packs, but lacked a thermometer. The facility's policy required verification and documentation of refrigerator, freezer, and room temperatures twice daily, with any deviations reported to the Nurse Leader or Health Care Administrator. However, the temperature log for November 2024 showed no documentation of freezer temperature monitoring, with horizontal lines recorded from November 1 through November 14, 2024. The DON confirmed that the freezer temperature should have been monitored and recorded twice daily, and the ice buildup should have been addressed.
Failure to Conduct Accurate Entrapment Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for a resident using bed rails, which could lead to potential entrapment, serious injury, or death. The deficiency was identified through observation, interviews, and document reviews, revealing that the entrapment zones for the resident's bed were not properly measured. Specifically, the entrapment zones 1, 2, 3, and 4 for the right side rail, as well as zones 6 and 7 for both side rails, were not assessed. This oversight was confirmed by the Maintenance Director, who admitted to not being aware of the resident's use of bilateral grab rails and failing to measure the necessary zones. The resident involved was observed with elevated bilateral grab rails, and the facility's policy requires that all bed systems leave no gap wide enough to entrap a resident's head or body. The Maintenance Director, responsible for conducting these assessments, acknowledged the failure to measure the entrapment zones as required. The Director of Nursing was informed and verified the findings, highlighting a lapse in the facility's adherence to its own policies and procedures regarding bed safety and entrapment risk assessments.
Failure to Follow Puree Recipe for Residents
Penalty
Summary
The facility failed to adhere to the puree recipe for seven residents on a puree diet, which posed a risk of not conserving the nutritive value of the food. During an observation of puree meal preparation, Cook 1 was seen adding chicken broth to cooked peas instead of using the liquid from the cooked peas as specified in the recipe. Additionally, Cook 1 added multiple tablespoons of thickener to the food items, deviating from the recipe instructions that called for one and one-half tablespoons of thickener. These actions were verified with the Registered Dietitian (RD).
Inaccurate Medical Record Documentation for Resident with Fracture
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record of a resident, identified as Resident 132, which had the potential to impact the resident's care needs. Resident 132 was admitted with a diagnosis of a right humerus fracture and had a fluctuating capacity to understand and make decisions. Despite this, the medical records showed that blood pressure readings were consistently taken from the resident's right arm, which was the site of the fracture. This was observed over a series of dates, with multiple blood pressure readings documented from the right arm. During an observation on November 13, 2024, a Licensed Vocational Nurse (LVN) attempted to take the resident's blood pressure from the right arm, but the resident refused. In a subsequent interview, the LVN confirmed that the blood pressure should not have been taken from the right arm due to the fracture. The Director of Nursing (DON) was informed of the situation and acknowledged that taking blood pressure from the right arm could cause pain and worsen the fracture. This oversight in documentation and practice highlights a deficiency in the facility's adherence to professional standards for safeguarding resident care.
Failure to Provide Equal Access to Nutritional Services
Penalty
Summary
The facility failed to provide equal access to nutritional services for a resident, identified as Resident 25, which posed a risk to the resident's rights. Resident 25, who was admitted with diagnoses including dementia and chronic kidney disease, was observed during a lunch meal waiting 40 minutes for her meal tray while other residents were already eating. The lunch was scheduled to be served at 1215 hours, but Resident 25 did not receive her meal until much later. A review of the facility's PCC list of diets did not include Resident 25's name, and staff, including the Director of Nursing, were unable to explain the delay in serving her meal.
Failure to Inform Residents of Complaint Procedures
Penalty
Summary
The facility failed to ensure that residents were informed of their rights and provided with information on how to formally complain to the State Agency about the care they received. During a resident council meeting, six residents expressed that they were unaware of the contact information for the State Licensing and Certification Office and did not know how to file a formal complaint. Instead, they mentioned that they would typically talk to the nurses if they had grievances or complaints. Interviews with the Activity Director and the Admissions Director confirmed that the residents were not provided with the necessary information on how to contact the State Agency. Although the State Agency's contact information was posted on the facility's consumer board, it was not included in the admission packet. The Admissions Director acknowledged that the information was not mentioned to the residents unless they specifically asked for it, and it was not part of the documents provided during admission.
Failure to Discontinue Sling Use as Ordered
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained their highest practicable physical well-being. Specifically, the facility did not carry out a physician's order to discontinue the use of a sling for the resident's right shoulder. The resident was observed wearing the sling during an initial tour of the facility, despite an order to discontinue its use being written on the same day. The order was noted without a time or signature from the licensed staff, and the Director of Nursing (DON) confirmed that the order was not executed. The Director of Staff Development (DSD) also verified that the order to discontinue the sling was not carried out as it should have been.
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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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