Santa Anita Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Temple City, California.
- Location
- 5522 Gracewood Ave., Temple City, California 91780
- CMS Provider Number
- 055293
- Inspections on file
- 120
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Santa Anita Convalescent Hospital during CMS and state inspections, most recent first.
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.
A resident with Alzheimer’s disease, Parkinson’s disease, and GERD, who lacked decision-making capacity and had a POA identified as responsible party, had an arbitration agreement in the medical record showing electronic signatures for both the resident and the POA even though neither actually signed the document. The admission coordinator and assistant administrator reported that a third‑party electronic admission system automatically marked documents as signed once the admission packet was opened, without requiring true signatures. The POA confirmed receiving but not signing the arbitration agreement, while facility policies required accurate, complete records and resident/representative signatures on admission and arbitration agreements only when they agree to the terms.
A resident with Alzheimer's disease, dementia, type 2 DM, and impaired decision-making capacity was prescribed Zyprexa 2.5 mg at bedtime for bipolar disorder manifested by screaming without cause. A Schizophrenia Diagnosis Checklist showed the resident did not meet criteria for schizophrenia, yet the consent form documented that the responsible party consented to Zyprexa for schizophrenia rather than bipolar disorder. The DON confirmed the discrepancy between the physician’s order and the consent form, despite a facility policy requiring that informed consent for psychotherapeutic drugs include disclosure of the correct reason for treatment and the nature of the illness.
A resident with Alzheimer’s disease, dementia, and type 2 DM was admitted with a POA identified and a long-standing primary care MD documented on a hospital face sheet, but the facility assigned a different attending MD without consulting the resident or POA. The Admissions Coordinator and Director of Marketing each acknowledged they did not speak with the POA or resident about physician choice and did not inform them of the assigned MD, assuming others would handle it. Facility policies on designation of attending physician and resident rights required that residents be asked to choose a personal MD prior to or upon admission and be informed when the facility designates one, but this process was not followed, resulting in the resident being placed under the care of a different MD without the POA’s knowledge or consent.
A resident with cataracts, muscle weakness, right arm pain, moderate cognitive impairment, and a documented high fall risk required supervision/touching assistance for ambulation per the MDS and care plan, which also directed staff to assist with transfers/locomotion and remind the resident to request help before walking. Despite this, the resident was allowed to walk independently outside a patio area while using a wheelchair like a walker, without staff present to supervise or assist. The resident lost balance, fell backward, and hit his head on the floor while attempting to grab the wheelchair, as confirmed by the resident, a respiratory therapist, and nursing staff, who acknowledged that required supervision and assistance were not provided at the time of the fall.
A resident with severe cognitive impairment, mobility limitations, and high fall risk did not have a person-centered care plan developed or implemented to address their need for supervision and assistance with ADLs. Despite assessments and staff confirming the need for substantial support, the facility failed to document or provide a care plan as required by policy.
A resident with cognitive impairment and significant physical disabilities was able to leave the facility unsupervised after a pedestrian assisted in opening a parking lot gate, which was remotely unlocked by a receptionist who did not verify the individual's identity. The resident was not accounted for during routine checks and was later found hospitalized after being missing for several hours. The facility did not follow its own procedures for monitoring and controlling access, resulting in the resident's elopement.
Surveyors identified that the facility did not maintain the building structure to prevent pest and rodent entry, including a tree branch touching the laundry roof, an open section of eaves, and gaps around drainpipes in the laundry area. Maintenance and environmental services staff acknowledged the issues, and pest control had previously recommended corrective actions that were not completed.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
A resident with dementia and significant care needs was not monitored or assessed for 72 hours after an alleged physical abuse incident, as required by facility policy. Nursing staff did not document the resident's condition for multiple shifts following the event, despite the resident's inability to verbalize changes and the facility's established procedures for post-incident monitoring.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with multiple medical conditions was served food items, including pasta and carrots, at temperatures below the facility's required standards. Observations and temperature checks confirmed that several food items on resident and test trays did not meet the policy's temperature requirements, and staff acknowledged the deficiency.
A dumpster in the back parking lot was observed overflowing with kitchen trash, including open food waste, and its lid was not closed. Staff confirmed the dumpster was smelly and surrounded by flies, and stated it should have been closed and not emitting odors. Facility policies require garbage to be properly contained and dumpsters to be kept closed and clean, which was not followed in this instance.
Two residents were found living in unsanitary conditions, including a dirty toilet seat with dried substances, cluttered and stained floors, a soiled towel left on a linen barrel, and an uncollected food tray. Staff acknowledged the room was dirty, and one resident expressed concern about the bathroom's cleanliness. Facility policy requires a clean and homelike environment, which was not maintained.
A resident with dementia, a history of falls, and muscle wasting was found with their call light on the floor and out of reach while needing assistance for a brief change. Staff confirmed the call light should have been accessible, as required by the care plan and facility policy, but it was not, preventing the resident from requesting help.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with a history of sexually inappropriate behavior and a physician's order for 1:1 supervision was not provided with a sitter, allowing the resident to sexually abuse another cognitively impaired resident. Prior incidents of inappropriate behavior were not properly reported or addressed, and required supervision was not implemented, leading to the abuse.
A resident with a history of wandering and violent behavior, who had a physician's order for 1:1 supervision, was not provided with a sitter as required. This lapse allowed the resident to enter the room of another cognitively impaired resident and commit a sexual assault, which was discovered by an LPN responding to a scream. The facility lacked a process to ensure sitter assignments were tracked and implemented, leading to the incident.
The facility did not ensure that most direct and indirect care staff received required in-service training on resident rights and facility responsibilities, as only a small portion of staff attended the scheduled session and there was no evidence of training for other shifts. Both the DSD and DSDC confirmed the training was incomplete, and facility policy requiring annual education and monitoring of attendance was not followed.
The facility did not provide required behavioral health training to 452 out of 552 direct and indirect care staff, as shown by incomplete attendance records and missing lesson plans. This deficiency affected staff knowledge and preparedness in caring for residents with behavioral health issues, particularly those housed in a secure dementia/behavioral unit.
A resident with moderate cognitive impairment and a history of psychiatric and behavioral issues engaged in sexually inappropriate behavior, which was observed by a 1:1 sitter. The incident was not promptly reported, and nursing staff did not develop or implement a care plan to address the behavior, contrary to facility policy. This failure placed other residents at risk.
A resident with intact cognitive abilities and multiple medical conditions repeatedly requested that certain individuals not visit and that her responsible party be changed. Despite these clear requests, staff did not update records or enforce her preferences, resulting in unwanted visits and emotional distress for the resident.
Two residents with severe cognitive impairment and high dependence for ADLs experienced falls due to lack of required supervision and assistance. One resident fell from bed when only one CNA provided care instead of the required two-person assist, while another resident with a physician's order for 1:1 supervision had an unwitnessed fall when no sitter was assigned during a shift.
A resident with multiple diagnoses, including Parkinson's disease and dementia, experienced significant weight loss that was not accurately documented on the MDS. The MDS nurse and DON confirmed the assessment did not reflect the resident's actual weight loss, contrary to facility policy requiring accurate documentation for care planning.
A resident with multiple complex medical conditions experienced significant weight loss, but staff did not complete a Change of Condition or implement the Registered Dietician's recommendations for nutritional interventions and physician notification, as required by facility policy.
A resident with a history of pneumonia, acute respiratory failure, and hemiplegia developed a skin rash and was prescribed Diphenhydramine HCl Cream 2% to be applied every eight hours as needed. Nursing staff failed to administer the medication for ten days, as confirmed by MAR review and staff interviews, despite the resident's continued symptoms and dependency on staff for care. The facility's policy required administration and documentation of medications per physician orders, which was not followed in this instance.
Three residents received antipsychotic medications without proper documentation of diagnoses, monitoring of target behaviors, or evidence that nonpharmacological interventions were attempted. For one resident, Quetiapine was given without supporting documentation for schizophrenia or monitoring of hallucinations. Another resident received Risperidone for behavioral symptoms without documentation of attempted NPIs, and staff reported no observed aggression. A third resident on Olanzapine was not properly monitored for behavioral symptoms as required, with medication records lacking necessary detail. Facility policies requiring behavioral monitoring and NPI use were not followed.
Nursing staff failed to verify the identity of two residents before administering medications and did not ensure that prescription labels for two other residents matched physician orders that included specific hold parameters for blood pressure and heart rate. These actions were inconsistent with facility policy, which requires identity verification and matching of physician orders, prescription labels, and the MAR prior to medication administration.
Two residents experienced medication errors when a nurse administered the wrong dose and form of docusate sodium to one resident and failed to check heart rate before giving amiodarone to another, resulting in a medication error rate above 5%. The nurse did not follow required procedures for resident identification and vital sign monitoring prior to medication administration, as confirmed by interviews and record review.
Surveyors found that a medication cart was left unlocked and unattended, and multiple medications for both current and discharged residents were not properly stored or labeled. Unused antibiotics for a discharged resident were not accounted for or destroyed as required, an unopened insulin pen was not refrigerated, and discontinued or bedhold medications remained in medication carts. Staff interviews confirmed these practices were not in line with facility policy.
Surveyors found that kitchen staff failed to clean can openers after use, left apple bar trays uncovered on a cooling rack, and used a cracked food tray with exposed rusted metal. Staff interviews confirmed these lapses, which were not in accordance with facility policies for food handling and storage.
Staff failed to label and date food items brought in by visitors for a resident, as required by facility policy. Unlabeled items, including ice cream, coffee, ice, and soda, were found in a staff breakroom refrigerator. Staff interviews confirmed the lack of labeling, which was not in compliance with the facility's procedures for handling outside food.
Six dumpsters in the back parking lot were found overflowing and not closed, containing facility and kitchen trash in clear and black plastic bags. The dietary director and an LVN confirmed that dumpsters should not be overflowing and must be closed to prevent attracting pests. Facility policy requires food waste to be placed in covered garbage and trashcans.
Three residents with cognitive and physical impairments did not receive required assistance with ADLs, including oral care, access to a communication board, and fingernail hygiene. One resident was observed with dry, cracked lips due to missed oral care, another was unable to communicate needs because a communication board was not available, and a third had dirty fingernails with fecal matter. Staff interviews and observations confirmed these lapses, despite facility policies requiring such care.
Staff did not consistently wear required PPE when entering rooms under contact precautions, and enhanced barrier precaution signage and supplies were missing for a resident with MDROs and an indwelling device. Additionally, respiratory equipment for two residents was not changed weekly as ordered, with items observed to be several weeks overdue for replacement.
Staff did not ensure privacy for a dependent resident during incontinent care by leaving the curtain and door open, and another resident was provided a cracked, chipped water pitcher with sharp edges. Both incidents failed to uphold resident dignity and respect as required by facility policy.
Two residents with significant medical needs and mobility limitations did not have their call lights within reach, as observed by staff. In both cases, the call lights were found on the floor and inaccessible, despite facility policy requiring that residents have access to a call system for assistance.
A resident with hemiplegia, hemiparesis, and cognitive impairment was found sleeping with their face against side rail pads that were visibly soiled with old food stains. Staff confirmed the pads were dirty, and the facility's infection control policy required daily disinfection. This failure created an unsanitary environment and potential infection risk.
A resident with multiple diagnoses and severe cognitive impairment was receiving physician-ordered oxygen therapy, which was consistently administered and documented in the MAR, but this therapy was not reflected on the MDS assessment. The MDS nurse acknowledged the omission, and facility policy requires accurate use of the RAI process for resident assessments.
A resident with multiple psychiatric and neurological diagnoses was prescribed Seroquel, but the care plan was not updated or revised to reflect current diagnoses or include nonpharmacological interventions. Staff and a psychiatrist noted inconsistencies in the resident's documented conditions, and the facility did not follow its policy requiring individualized, updated care plans for psychotropic medication use.
Two residents did not receive proper G-tube care, including failure to elevate the head of bed during tube feeding as ordered by a physician and failure to maintain a clean valve on the G-tube. Staff confirmed these lapses, and the facility lacked a specific policy for valve maintenance, despite having a general infection control program.
A resident receiving hemodialysis did not have consistent and complete documentation of their AV shunt access site assessments, as required by facility policy. Multiple dialysis communication records were found to be incomplete, lacking necessary information about infection signs and vascular access status. Nursing leadership confirmed that incomplete records were not followed up with the dialysis center, leading to gaps in care documentation.
A resident with depression and suicidal ideation did not receive required one-to-one sitter supervision as ordered and care planned. Despite clear documentation and facility policy mandating immediate supervision, no staff were assigned to sit with the resident during the night shift, and staff were unaware of the requirement. The lack of implementation was confirmed by direct observation and staff interviews.
A resident with documented dislike of pasta was repeatedly served meals containing pasta or noodles, despite her care plan and dietary profile specifying this preference. Staff failed to clarify the resident's definition of pasta, resulting in her receiving unwanted food items and expressing dissatisfaction with her meals.
A resident with multiple health conditions, including COPD, had a physician's order for oxygen therapy as needed. Observations and staff interviews revealed that oxygen was not set up or administered, yet the MAR inaccurately documented that oxygen was given over several days. Multiple nurses confirmed the documentation was incorrect, failing to meet the facility's policy for accurate nursing records.
A resident signed an arbitration agreement that did not include required information about the use of a neutral arbitrator or the selection of a venue convenient to both parties. Staff members were unaware of the need to provide this information, and the facility had recently adopted a shortened agreement form that omitted these details, resulting in an incomplete understanding of the agreement for the resident.
Surveyors found that two residents were exposed to unsafe conditions due to exposed bed control and call light wires, and an overflowing trash can with used PPE was observed in a resident room. Staff interviews confirmed these conditions were not acceptable and did not follow facility policy for maintaining a safe, clean, and comfortable environment.
A resident with severe cognitive impairment and behavioral issues tipped over the wheelchair of another resident with dementia and Parkinson's Disease, causing the latter to fall and sustain a minor head injury. Staff and documentation confirmed the incident was witnessed and that the resident responsible was not adequately monitored, resulting in a failure to protect residents from abuse as required by facility policy.
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.
Inaccurate Electronic Arbitration Agreement Signatures in Medical Record
Penalty
Summary
The facility failed to maintain accurate medical records for a resident when an arbitration agreement in the resident’s admission record showed electronic signatures that were not actually provided by the resident or the responsible party. The resident had been admitted with Alzheimer’s disease, Parkinson’s disease, and GERD, and the History & Physical documented that the resident did not have capacity to understand and make decisions. The admission record identified a responsible party holding power of attorney. Despite this, the arbitration agreement in the electronic admission packet reflected an electronic signature for the resident on 2/10/2026 and for the responsible party on 3/7/2026. During interviews and record review, the Admission Coordinator acknowledged that the arbitration agreement’s electronic signatures for the resident and responsible party were not accurate. The Admission Coordinator explained that the third‑party electronic admission system automatically records an electronic signature for the resident once the admission packet is opened, and marks documents as signed without requiring an actual signature from the resident or responsible party. The Assistant Administrator confirmed that the facility used this third‑party system and that signatures may not be accurately reflected. The responsible party stated that she received the electronic arbitration agreement but did not sign it and did not intend to sign any arbitration agreement for the resident, noting that the resident does not sign legal documents. Facility policies required that medical records be accurate, timely, and complete, and that residents or their representatives sign and date the admission agreement, including arbitration agreements, only if they agree to the terms.
Failure to Obtain Accurate Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain accurate informed consent for the use of the antipsychotic medication Zyprexa for a resident. The resident was admitted and later readmitted with diagnoses including Alzheimer's disease, dementia, and type 2 DM, and an MDS assessment showed moderately impaired cognitive skills and a need for assistance with activities of daily living. A Schizophrenia Diagnosis Checklist dated 2/12/2026 indicated the resident did not meet criteria for schizophrenia. However, the History & Physical dated 2/25/2026 documented a present illness of bipolar disorder and stated the resident did not have the capacity to understand and make decisions. On 2/25/2026, the physician's order directed Zyprexa 2.5 mg by mouth at bedtime for bipolar disorder manifested by screaming without cause. The facility’s consent form, also dated 2/25/2026, documented that the resident’s responsible party was made aware of and consented to Zyprexa 2.5 mg for a diagnosis of schizophrenia with the behavior of screaming without cause, rather than for bipolar disorder as written in the physician’s order. In an interview, the DON confirmed that the consent obtained was for schizophrenia and not for bipolar disorder, and stated it was important to obtain the correct consent so the resident and responsible party would know and be able to choose the appropriate treatment plan. The facility’s informed consent policy required that the attending physician disclose the reason for treatment and the nature and seriousness of the resident’s illness when obtaining informed consent for therapies including psychotherapeutic drugs.
Failure to Honor Resident’s Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose an attending physician prior to or upon admission, as required by facility policy. The resident was admitted with diagnoses including Alzheimer’s disease, dementia, and type 2 DM, and had moderately impaired cognitive skills for daily decision making, requiring varying levels of assistance with ADLs. The admission record listed a specific physician (MD 3) as the primary physician, while a face sheet faxed from a general acute care hospital identified a different physician (MD 1) as the resident’s primary care physician. The resident’s POA (RP 1) was identified in the admission record, but neither the resident nor RP 1 was asked to choose an attending physician at or before admission. RP 1 reported not being informed that MD 1 was not the attending physician until a change of condition occurred, and stated she was never told the resident would be assigned a new physician or asked about her choice, despite MD 1 having been the resident’s primary physician for over 10 years. The Admissions Coordinator acknowledged assigning the resident to MD 3 without asking RP 1 about physician choice and did not notify RP 1 of the change, stating it was not her responsibility. The Director of Marketing stated that when the referral was received, she assigned the resident to one of the facility doctors without speaking to the resident or RP 1 about their choice of attending physician and did not follow up, assuming another staff member would do so. Review of the facility’s policies on Designation of Attending Physician and Resident’s Rights confirmed that residents must be asked to choose a personal attending physician prior to or upon admission and be informed when the facility designates one, which did not occur in this case, as acknowledged by the Administrator.
Failure to Supervise High Fall-Risk Resident During Ambulation
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance to prevent a fall for a resident assessed as high risk for falls. The resident had diagnoses including cataract, muscle weakness, and right arm pain, and an MDS dated 10/24/2025 documented moderately impaired cognitive skills for daily decision-making. The MDS also indicated the resident required supervision/touching assistance for ambulation (walking 10 feet, 50 feet with two turns, and 150 feet) and setup/cleanup assistance for toileting hygiene, lower body dressing, footwear, and personal hygiene. The resident’s fall risk assessment dated 12/3/2025 identified the resident as high risk for falls. The care plan for fall risk, revised 10/30/2025, directed staff to provide assistance with transferring and locomotion as needed and to educate/remind the resident to request assistance prior to transfer/ambulation. A separate care plan for elopement risk, also revised 10/30/2025, instructed staff to address wandering behavior by walking with the resident and to evaluate the need for additional supervision. On 12/16/2025, the resident experienced a witnessed fall outside the patio area while entering another unit, during which the resident fell backward and hit his head on the floor. Progress notes from that date at 9:00 AM documented that the resident fell outside the patio area while entering another unit and fell backward while trying to grab his wheelchair. In an interview, the resident stated he had been walking by himself while pushing the wheelchair when he fell outside the unit. A respiratory therapist reported observing the resident using his wheelchair like a walker, losing balance, and falling backward while she was only present to open the door and was not supervising the resident; she confirmed the resident was by himself at the time of the fall. The RN supervisor and QA nurse both confirmed that, based on the MDS and care plan, the resident required supervision/touching assistance when walking, meaning a person should be with the resident to guide and help as needed, and acknowledged that no one was with the resident and he did not have the required assistance at the time he was ambulating and fell. Facility policies on fall management, care planning, and safety of residents required development and implementation of care plans and provision of a safe environment, but the resident was allowed to ambulate without the indicated supervision and assistance when the fall occurred.
Failure to Develop and Implement Person-Centered Care Plan for Resident Requiring ADL Assistance
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for one resident who required supervision and assistance with Activities of Daily Living (ADLs). The resident had multiple diagnoses, including lack of coordination, difficulty walking, dementia, and Parkinson's Disease, and was assessed as having severely impaired cognitive skills and high dependency for various ADLs such as toileting, bathing, dressing, and transfers. Multiple assessments, including the Minimum Data Set and Fall Risk Assessments, indicated the resident was at high risk for falls and required substantial to maximal assistance or supervision for mobility and transfers. Interviews with staff, including a CNA and the Director of Rehab, confirmed the resident needed supervision or touching assistance during walking and transfers. Despite these documented needs and facility policy requiring comprehensive, person-centered care plans, a review of the resident's medical chart revealed no care plan addressing the need for supervision or assistance with ADLs. Staff interviews, including with an LVN and the DON, confirmed that no specific care plan had been developed or implemented for this resident's supervision or assistance needs. The facility's policy emphasized the importance of individualized care planning involving the interdisciplinary team, but this process was not followed for the resident in question.
Failure to Supervise and Prevent Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to supervise and ensure the safety of a resident in accordance with its Wandering and Elopement Policy and Procedure. The resident, who had chronic obstructive pulmonary disease, chronic pulmonary edema, and bilateral below-the-knee amputations, was moderately cognitively impaired and required significant assistance with activities of daily living. Despite these needs, the resident was able to leave the facility unsupervised through a parking lot gate after an unknown pedestrian pressed the gate button, which was then opened by the receptionist without verifying the identity or purpose of the individual at the gate. The resident was last seen in the facility's patio area in the afternoon and was not accounted for during routine checks by staff. Multiple staff interviews revealed that the resident was not observed returning to his room at the usual time, and there was uncertainty among staff regarding supervision responsibilities in the patio area. The facility's security camera footage later confirmed that the resident exited the facility through the parking lot gate with the assistance of a pedestrian, and staff did not realize the resident was missing until several hours later during shift change and meal distribution. The receptionist, who was responsible for monitoring the parking lot gate, did not follow the facility's protocol to verify the identity of individuals requesting access. This lapse allowed the resident to leave the premises undetected. The resident was eventually found by a neighbor and admitted to a general acute care hospital with decompensated congestive heart failure and pleural effusion after being exposed to the outside environment for an extended period. The facility's failure to provide adequate supervision and to follow established procedures directly led to the resident's elopement and subsequent hospitalization.
Failure to Maintain Building Structure and Prevent Pest Entry
Penalty
Summary
The facility failed to maintain the building structure in a manner that prevented possible entry points for pests and rodents. Observations revealed a tree branch with foliage was in direct contact with the roof structure of the laundry department, creating a pathway for pests and rodents to access the facility. Additionally, a section of the eaves outside the laundry department, measuring 30 inches by 4 inches, was left open without a wood cover or frame, further increasing the risk of pest and rodent entry. Inside the laundry room, a metal frame on the floor surrounding two drainpipes had large gaps and holes, providing additional access points for pests and rodents. Interviews with the Maintenance Supervisor and Environmental Services Director confirmed awareness of the issues, with both acknowledging the importance of maintaining the facility structure and following pest control recommendations. The pest control service report had previously identified the vegetation contact as a risk and recommended trimming, but this action was not completed. The facility's policy and procedure indicated that the maintenance department is responsible for ensuring the safety and operability of the building, grounds, and equipment at all times to protect the health and safety of residents, visitors, and staff.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events, observations, or resident conditions related to the incident.
Failure to Monitor and Document Resident After Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that a resident was assessed and monitored for 72 hours following an alleged incident of physical abuse, as required by the facility's policy and procedure. The resident, who had diagnoses including adult failure to thrive, dementia, and weakness, was dependent on staff for most activities of daily living and had moderately impaired cognitive skills. After an alleged episode of physical abuse by a certified nurse assistant, the care plan was updated to include regular assessment of the resident's emotional status. However, a review of the medical records revealed that there was no documentation of monitoring for the resident's condition during all shifts on the day following the incident. Interviews with nursing staff and facility leadership confirmed that 72-hour monitoring and documentation should have been completed for each shift, especially given the resident's inability to verbalize changes in condition. The facility's policy required licensed nurses to document the resident's status every shift for at least 72 hours after a change in condition, but this was not done. The absence of monitoring and documentation was acknowledged by multiple staff members, including the Director of Nursing, who confirmed that the required assessments were not performed as per policy.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Failure to Serve Food at Proper Temperatures
Penalty
Summary
The facility failed to serve food at the proper temperatures as required by its policy and procedure titled Food Temperatures. During an interview, a resident reported that her food was usually served cold. Observation and temperature checks confirmed that the food items served to the resident, including pasta and carrots, were below the required serving temperature of more than 140 degrees Fahrenheit, with the pasta at 123°F and carrots at 108°F. Additional test trays also showed food items, such as chicken and rice casserole and carrots, being served below the required temperature, and milk being served above the acceptable cold temperature of less than 41°F. The resident involved had a medical history including diabetes mellitus, hypertension, and depression, and required varying levels of assistance with activities of daily living, including setup or clean up assistance with eating. Both the Quality Assurance Nurse and the Administrator confirmed that the food temperatures did not meet the facility's policy requirements at the time the food was served to the resident. The facility's policy specified that food not meeting the required temperatures should be reheated or chilled to the proper temperature before serving, which was not done in this instance.
Improper Disposal and Overflowing Dumpster
Penalty
Summary
During an observation, one of two dumpsters located in the facility's back parking lot was found to be overflowing, with its lid not closed. The dumpster contained kitchen trash, including crushed eggshells in an open box, and emitted a strong odor of spoiled or rotten food. Flies were visibly present around the dumpster. Staff interviews confirmed that the dumpster was overflowing, smelly, and surrounded by flies, and that it should have been closed and not emitting odors. The Dietary Director and Dietary Aid both stated that dumpsters are supposed to be closed at all times and that kitchen trash should be double-tied in plastic bags before being placed in the dumpster to prevent attracting insects and rodents. A review of the facility's policies and procedures revealed that garbage and trash cans are to be used according to manufacturer guidelines, cleaned routinely, and that food waste should be placed in covered garbage and trash cans. The pest control policy also indicated that garbage and trash are not permitted to accumulate in any part of the facility. The observed practice of leaving the dumpster overflowing and uncovered, with improperly disposed food waste, was not in accordance with these policies.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, sanitary, and home-like environment for two of three sampled residents by not ensuring the cleanliness and orderliness of their living space. Observations and interviews revealed that the toilet seat in the residents' room had brownish to reddish dry substances, and the floor was cluttered with empty cups, cup covers, food wrappers, and food stains. Additionally, a dirty white towel with a brownish substance was found placed on top of a covered linen barrel instead of inside it, and an old food tray from dinner had not been picked up. Both the housekeeping staff and the assistant administrator acknowledged the room was dirty, with the assistant administrator specifically noting the presence of dry feces on the toilet seat and the potential for the environment to harbor bacteria and attract pests. Resident records indicated that one resident had intact cognitive skills while the other had severely impaired cognitive skills, both with medical histories including diabetes and a history of falls. The infection preventionist nurse confirmed that food should have been removed after meals, towels should be properly stored for infection control, and the floor and toilet should be kept clean. One resident expressed concern about the unclean bathroom and the possibility of becoming ill as a result. The facility's policy and procedures require staff to maintain a safe, clean, and homelike environment, which was not followed in this instance.
Call Light Not Kept Within Reach for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's call light was within reach, as required by the facility's policy and the resident's care plan. The resident, who had diagnoses including dementia, a history of falls, and muscle wasting, was assessed as being at high risk for falls and required varying levels of assistance with daily activities. The care plan specifically indicated that the call light should be attached and within reach, and the facility's policy also required the call light to be accessible to residents. During an observation, the resident's call light was found on the floor, out of reach, while the resident was attempting to indicate a need for a brief change. Staff interviews confirmed that the call light should not have been on the floor and that the resident knew how to use it to request assistance. The failure to keep the call light within reach meant the resident was unable to call for help when needed, contrary to both the care plan and facility policy.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Provide Required Supervision Resulting in Sexual Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from sexual abuse by another resident. The resident who committed the abuse had a physician's order for one-to-one (1:1) supervision due to wandering and sexually inappropriate behaviors, but was not provided with a sitter during the night shift. This lack of supervision allowed the resident to enter another resident's room and commit sexual abuse, which was discovered by a nurse responding to a scream. The nurse found the perpetrator on top of the victim, whose pants and diaper were pulled down above the knees. The incident was confirmed by multiple staff interviews and documentation. Prior to the incident, there were documented episodes of the perpetrating resident engaging in sexually inappropriate behavior, such as playing with his private area. These behaviors were observed by certified nursing assistants but were either not reported promptly to licensed staff or not documented and addressed according to facility policy. The facility's change of condition policy required that such behaviors be reported to the physician, monitored, and documented, but this was not done. The lack of timely reporting and intervention meant that no new or updated interventions were developed to prevent further incidents. The victim was a resident with severe cognitive impairment, requiring significant assistance with daily activities and supervision for safety. The perpetrator had a history of paranoid schizophrenia, violent behavior, and was HIV positive. The failure to provide required supervision and to act on prior sexually inappropriate behaviors directly led to the incident of sexual abuse. Staff interviews confirmed that the required 1:1 supervision was not in place at the time of the incident, and that there was no process to ensure compliance with sitter assignments.
Failure to Provide 1:1 Supervision Results in Resident-to-Resident Sexual Assault
Penalty
Summary
The facility failed to ensure adequate supervision and accident hazard prevention for a resident with a known history of wandering and behavioral issues. One resident, diagnosed with paranoid schizophrenia, violent behavior, and HIV, was assessed as having a significant risk for wandering and had a physician's order for a 1:1 sitter to provide constant supervision. Despite this order, the resident was not assigned a 1:1 sitter during the overnight shift, and there was no process in place, such as a sitter log, to ensure compliance with the order. As a result of this lack of supervision, the resident with wandering behavior entered the room of another resident who had severe cognitive impairment due to dementia, depression, and schizophrenia. The cognitively impaired resident required substantial assistance with daily activities and was unable to protect herself. During the incident, the resident with wandering behavior was found on top of the other resident, whose pants and diaper were pulled down, and he admitted to having sex with her. Staff interviews and record reviews confirmed that the 1:1 sitter was not provided as ordered, and the facility's policies required that physician orders be carried out completely and that residents be protected from abuse. The absence of a sitter and lack of monitoring directly led to the incident, which was discovered when a nurse responded to a scream and found the resident in the act. The event was reported to supervisory staff, law enforcement, and other relevant authorities.
Failure to Provide Resident Rights Training to Majority of Staff
Penalty
Summary
The facility failed to ensure that the majority of its staff, specifically 524 out of 552 direct and indirect care staff, received in-service training on resident rights and facility responsibilities as required by facility policy. Record review showed that the Resident Rights in-service was scheduled for April 2025, but attendance records indicated that only 28 staff members attended, primarily from the night shift. There were no sign-in sheets or evidence of training for the other shifts, and both the Director of Staff Development (DSD) and the Staff Development Consultant (DSDC) confirmed that the in-service was not provided to all staff. The DSD stated it was not possible to keep track of all staff attendance, and the DSDC acknowledged the significant impact this lack of training could have on residents. Interviews with the DSD and DSDC further revealed that the facility's policy requires annual and as-needed training on resident rights for all staff, and that department heads are responsible for ensuring staff attendance at mandatory in-services. The DSD admitted that incomplete in-service attendance meant staff might be unaware of critical information regarding resident rights, including the right not to be abused and the right to receive or decline care. The facility's policy also states that lack of staff attendance should be reported to the administrator and department heads, but this process was not followed, resulting in a deficiency in staff education on resident rights.
Failure to Provide Behavioral Health Training to Majority of Staff
Penalty
Summary
The facility failed to provide behavioral health training to 452 out of 552 direct and indirect care staff, as required by the facility assessment and policy. Record reviews showed that the annual in-service calendar scheduled behavioral health training for November, but attendance records from the December in-service indicated that only 100 staff, primarily from the morning shift, participated. There was minimal representation from the evening shift and only one night shift staff attended, leaving the majority of staff without the required training. The Director of Staff Development confirmed that no follow-up was conducted to ensure all shifts received the training, and the Director of Nursing acknowledged the absence of a lesson plan in the in-service binder, further indicating the training was incomplete. Interviews with staff, including a CNA and an LVN, revealed that the lack of behavioral health in-service could impact their ability to provide appropriate care and identify resident behaviors. The facility's policies require the Director of Staff Development to assess educational needs, plan and implement training, and maintain attendance records with lesson plans, but these requirements were not met. The facility assessment identified a secure unit for residents with dementia or behavioral issues, highlighting the importance of this training for the 49 residents with behavioral health concerns.
Failure to Develop and Implement Care Plan for Sexually Inappropriate Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's sexually inappropriate behavior, specifically the act of touching his private area and making inappropriate requests to a staff member. The resident, who had diagnoses including paranoid schizophrenia and violent behavior, was assessed as having moderate cognitive impairment and required supervision for several activities of daily living. Despite an incident being observed and reported by a 1:1 sitter, there was a delay in reporting the behavior to nursing staff, and no care plan interventions were initiated to address the inappropriate sexual behavior. Interviews with nursing staff confirmed that the incident should have been reported immediately and that a resident-centered care plan should have been developed and implemented to ensure the safety of the resident and others. A review of facility policy indicated that care plans must be updated to address changes in behavior, but this was not done following the incident. The lack of timely reporting and failure to initiate appropriate care planning placed other residents at risk.
Failure to Honor Resident's Rights to Visitor Choice and Responsible Party
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of her choice and to designate her own responsible party. The resident, who had diagnoses including type 2 diabetes mellitus, end stage renal disease, and required dialysis, was cognitively intact and capable of making her own decisions. Despite multiple documented requests from the resident to restrict visits from certain individuals and to change her responsible party to another person, these requests were not acted upon by facility staff. Documentation in the resident's records, including social services notes and interdisciplinary team notes, showed that the resident repeatedly expressed her desire not to have visits from specific visitors and to have a different responsible party involved in her care. The resident also communicated her wishes directly to staff members, including certified nursing assistants and social services staff, and requested that her medical records be updated to reflect these changes. However, the facility did not update the records or enforce the resident's preferences, resulting in unwanted visits and continued involvement of the previously designated responsible party. During interviews and observations, the resident stated she felt unsafe and uncomfortable due to the facility's failure to respect her choices regarding visitors and responsible party. Staff confirmed that the resident had the capacity to make these decisions and that her requests should have been honored. The facility's own policy required staff to respect residents' rights to self-determination and to document personal preferences, but these procedures were not followed in this case.
Failure to Provide Adequate Supervision and Assistance Resulting in Resident Falls
Penalty
Summary
The facility failed to provide adequate safety and supervision for two out of three sampled residents, resulting in falls. For one resident with diagnoses including dementia, osteoporosis, metabolic encephalopathy, muscle weakness, and a recent right femur fracture, the Minimum Data Set (MDS) indicated severe cognitive impairment and total dependence on staff for all activities of daily living (ADLs). On the evening of 2/17/2025, a Certified Nurse Assistant (CNA) provided bed mobility, dressing, and personal hygiene care to this resident without the assistance of a second staff member, despite facility policy and staff interviews confirming that a two-person assist was required for such dependent residents. During this care, the resident rolled off the bed and fell. Another resident, admitted with cerebral ischemia, dementia, and a history of facial fractures from a previous fall, also had severely impaired cognition and required varying levels of assistance for ADLs. Following a physician's order for continuous one-on-one supervision (1:1 sitter) after a fall, the facility failed to document or provide evidence that a sitter was assigned during a specific shift. On 4/28/2025, this resident experienced an unwitnessed fall and was found on the floor, despite the order for a 1:1 sitter and a bed alarm. Review of staffing assignments confirmed the absence of a designated sitter during the relevant shift. Interviews with facility staff, including the Director of Staff Development (DSD) and the Director of Nursing (DON), confirmed that the required supervision and assistance were not provided according to the residents' care plans and physician orders. Facility policies reviewed emphasized the need for appropriate staff assistance and supervision to prevent falls, but these were not followed in the cases described, directly leading to the residents' falls.
Failure to Accurately Document Resident Weight Loss on MDS
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's weight loss on the Minimum Data Set (MDS) as required by facility policy. Specifically, a resident with diagnoses including Parkinson's disease, dementia, type 2 diabetes mellitus, and dysphagia experienced a significant weight loss, dropping from 163 pounds to 149 pounds within a month, which equates to an 8.59% loss. Over a six-month period, the resident lost 19% of their body weight. However, the MDS did not reflect this weight loss, incorrectly indicating that the resident had not lost 5% or more in the last month or 10% or more in the last six months. During interviews, the MDS nurse acknowledged that the MDS was inaccurate and should have documented the resident's weight loss. The DON also confirmed that the MDS should accurately reflect weight loss to enable the development of an appropriate care plan and to monitor trends. Facility policy requires that all information recorded in the MDS must reflect the resident's status at the time of the assessment, but this was not followed in this case.
Failure to Address Significant Weight Loss and Follow Dietician Recommendations
Penalty
Summary
The facility failed to provide appropriate nutritional care and services for one resident who experienced significant weight loss. Despite documented weight loss of 8.59% in one month and 19% over six months, the facility did not complete a Change of Condition (COC) or follow the Registered Dietician's (RD) recommendations. The RD had advised a referral to the physician for blood sugar monitoring, the addition of sugar-free home parenteral nutrition and Boost Glucose Control, and lab orders. However, there was no evidence in the medical records that these recommendations were implemented, nor was there documentation of physician notification or follow-up actions. Interviews with facility staff, including the RD, MDS nurse, and Director of Nursing, confirmed that the expected protocol was not followed. The facility's policy required notification of the attending physician and completion of a COC for significant weight changes, but these steps were not taken. The resident involved had multiple diagnoses, including Parkinson's disease, dementia, type 2 diabetes, and dysphagia, and required substantial assistance with daily activities. The failure to act on the RD's recommendations and to complete required documentation constituted a deficiency in the facility's nutritional care practices.
Failure to Administer Ordered Topical Medication for Skin Rash
Penalty
Summary
A deficiency occurred when nursing staff failed to administer Diphenhydramine HCl Cream 2% as ordered by a physician for a resident with a documented skin rash. The resident, who was admitted with multiple diagnoses including pneumonia, acute respiratory failure with hypoxia, and hemiplegia, was noted to have a rash on the right arm, left chest, and left leg. The physician ordered the topical medication to be applied every eight hours as needed for the rash, but review of the Medication Administration Record (MAR) showed that the medication was not administered for a period of ten days. Interviews with the resident and the treatment nurse confirmed that the cream was not applied during this time, and the nurse acknowledged that the medication should have been given as ordered. The resident's cognitive skills were moderately impaired, and they were dependent on staff for personal care. During the period when the medication was not administered, the resident continued to have rashes, as observed by the treatment nurse. The facility's policy required medications to be administered and documented per physician orders, but this was not followed in this case. The Director of Nursing confirmed that the medication was not given as ordered and acknowledged the importance of following physician instructions for medication administration.
Failure to Prevent Unnecessary Use of Psychotropic Medications and Chemical Restraints
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure that three of five sampled residents were free from chemical restraints. For one resident, Quetiapine (Seroquel) was administered without proper monitoring of target behaviors, without clinical documentation supporting a diagnosis of schizophrenia, and without evidence that nonpharmacological interventions (NPI) were attempted or provided. Interviews with facility staff and a psychiatrist revealed that the resident did not exhibit hallucinations or delusions, and there was no clear documentation of schizophrenia in the clinical record. Nursing progress notes and medication administration records showed zero episodes of the target behavior, and staff acknowledged that NPI interventions were not documented or implemented prior to or during the use of the antipsychotic medication. Another resident continued to receive Risperidone (Risperdal) for a diagnosis of bipolar disorder manifested by hitting staff during care, but there was no documentation of NPI interventions attempted or provided. Staff interviews indicated that the resident was generally calm, did not display physical aggression, and responded well to familiar caregivers. Review of the resident's care plan and medication records confirmed the absence of NPI monitoring or documentation, and staff stated that such interventions should have been implemented to address the resident's behaviors. A third resident was prescribed Olanzapine for psychosis manifested by striking out during care, but the facility failed to monitor the resident's behavior as required by the care plan and physician's order. The medication administration record only indicated yes/no responses for suicidal ideation without quantifying the frequency of behaviors, making it difficult to assess the effectiveness of the medication or the need for dose adjustments. The facility's policies required monitoring and documentation of behaviors and the use of nonpharmacological interventions, but these were not followed for the residents in question.
Failure to Verify Resident Identity and Match Prescription Labels with Physician Orders During Medication Administration
Penalty
Summary
The facility failed to ensure safe and accurate medication administration for four residents by not properly verifying resident identity and by not ensuring that prescription labels matched physician orders with specific administration parameters. During medication passes, two licensed vocational nurses (LVNs) administered medications to two residents without using appropriate identifiers to confirm their identities. In both cases, the nurses either called the resident by name or responded to a resident's request for medication but did not check identification bracelets or ask the residents to state their names, as required by facility policy. Both residents confirmed that their identities were not verified prior to receiving their medications. Additionally, the facility did not ensure that prescription labels for two other residents matched the physician orders, which included specific parameters for holding blood pressure or heart rate medications. For one resident, the physician's order for Spironolactone included instructions to hold the medication if the systolic blood pressure was below 110 mmHg or the heart rate was below 60 bpm, but the prescription label did not reflect these parameters. Similarly, another resident's order for Amiodarone included a hold parameter for heart rate below 60 bpm, which was also missing from the prescription label. In both cases, the nurses acknowledged the discrepancies between the physician orders, the medication administration record (MAR), and the prescription labels. The facility's policy and procedures require verification of resident identity before medication administration and mandate that the prescription label, physician order, and MAR must match, with any discrepancies resolved prior to administration. The Director of Nursing confirmed that these steps are necessary to prevent medication errors and ensure safe medication practices. However, observations and interviews revealed that these procedures were not consistently followed, resulting in the identified deficiencies.
Medication Error Rate Exceeds 5% Due to Incorrect Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors identified out of 33 observed opportunities, resulting in a 6.06% error rate. In the first instance, a nurse administered the incorrect dose and form of docusate sodium to a resident. The resident was ordered to receive docusate sodium 100 mg oral tablet four times daily, but instead received a 250 mg capsule. The nurse did not verify the resident’s identity through standard procedures such as checking the identification bracelet or confirming the resident’s name and date of birth prior to administration. The nurse later acknowledged the error and confirmed that the medication given did not match the physician’s order. In the second instance, a nurse failed to check a resident’s heart rate prior to administering amiodarone 200 mg, as required by the physician’s order, which specified to hold the medication if the heart rate was less than 60 bpm. The nurse stated that vital signs were checked earlier in the morning but were not documented until after medication administration. The nurse admitted that the heart rate should have been checked immediately before giving the medication, in accordance with the order’s parameters. The resident’s care plan and physician’s order both indicated the necessity of monitoring vital signs prior to administration of cardiac medication. Both incidents were observed during medication administration and were confirmed through interviews with the involved nurse and the Director of Nursing. The facility’s policy and procedures require that medications be administered only as prescribed, with proper resident identification and completion of any required vital sign checks prior to administration. The observed practices did not align with these requirements, resulting in the cited deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed that one of four medication carts (Unit A medication cart 1) was left unlocked and unattended, contrary to the facility's policies and procedures regarding medication security. The administrator confirmed the cart was unlocked with no staff present, and a Licensed Vocational Nurse (LVN) admitted to forgetting to lock the cart when leaving to attend to a resident. Interviews with other nursing staff confirmed that medication carts are required to be locked at all times when unattended to prevent unauthorized access. Further observations and interviews revealed that medications and biologicals were not properly stored or labeled for several current and discharged residents. For one discharged resident, an antibiotic bubble pack with remaining doses was found in a medication cart, and staff could not account for all doses or provide documentation of their destruction. The facility's policy requires unused medications to be removed from storage and destroyed in the presence of two licensed healthcare professionals, with proper documentation, but this process was not followed. Additional deficiencies included improper storage of an unopened Lantus SoloStar insulin pen, which was found at room temperature in a medication cart instead of being refrigerated as required by manufacturer instructions. Multiple discontinued, controlled, and bedhold medications for residents who were either transferred or discharged were also found stored in medication carts alongside active medications. Staff interviews confirmed that these medications should have been removed from the carts and stored separately or destroyed according to facility policy.
Failure to Maintain Sanitary Food Handling and Storage Practices
Penalty
Summary
Surveyors observed multiple failures in food handling practices within the facility's kitchen. Two can openers were found to be dirty, with visible food residue and sticky gunk, including remnants of tomato sauce. Staff interviews confirmed that the can openers were not cleaned after use, contrary to facility policy, which requires sanitization between uses. Additionally, two trays of apple bar were observed on a cooling rack in the walk-in refrigerator without being fully covered, as required by the facility's food storage policy. Staff acknowledged that the trays should have been properly sealed to prevent contamination. Further inspection revealed a food tray with a crack exposing rusted metal, which was confirmed by both the Dietary Director and a dietary aide. Facility policy mandates that chipped or cracked service ware be discarded to maintain a sanitary environment. Staff interviews reiterated the importance of covering food properly and discarding compromised trays to prevent contamination and ensure safety. Review of relevant facility policies confirmed that these practices were not followed as required.
Failure to Label and Date Resident Food Brought in by Visitors
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the labeling and storage of food items brought in by visitors for residents. During an observation in the Unit B staff breakroom, several food items, including ice cream, coffee, ice, and soda, were found in the refrigerator without labels indicating the resident's name or the date the items were brought in. Interviews with the assistant director of nursing (ADON) and a registered nurse confirmed that these items were not labeled as required by facility policy. A review of the facility's policy titled 'Food Brought in by Visitors' revealed that all food from outside sources should be stored in sealable containers labeled with the resident's name and the date the food was brought in. The policy also specified that perishable food should be discarded after two hours at bedside, and if refrigerated, it should be labeled, dated, and discarded after 48 hours. The failure to label these items was acknowledged by staff and was not in accordance with the established procedures.
Improper Disposal and Overflowing Dumpsters
Penalty
Summary
Six dumpsters located in the facility's back parking lot were observed to be overflowing and not properly closed. During observations and interviews, the dietary director confirmed that the dumpsters contained both facility and kitchen trash in clear and black plastic bags and acknowledged that the dumpsters were not supposed to be overflowing. The dietary director and a licensed vocational nurse both stated that dumpsters and trashcans should not be overflowing and must be closed properly to prevent attracting rodents, flies, and insects. A review of the facility's policy and procedure on garbage and trashcan use and cleaning indicated that food waste should be placed in covered garbage and trashcans.
Failure to Assist Residents with ADLs, Oral Care, Communication, and Hygiene
Penalty
Summary
Three residents with significant cognitive and physical impairments did not receive necessary assistance with activities of daily living (ADLs), as observed and documented by surveyors. One resident, who had dementia, diabetes, and depression, was found to be totally dependent on staff for oral hygiene and personal care. Despite care plan instructions for daily oral care, this resident was observed with dry, scaly, and cracked lips, and staff interviews confirmed that oral care was not consistently provided. Another resident, with a history of stroke, emphysema, and failure to thrive, had a care plan indicating the need for a communication board due to a language barrier and severely impaired decision-making skills. During observation, the resident attempted to communicate needs through gestures, but the communication board was not available in the room, and staff were unable to understand the resident’s requests. Staff interviews confirmed that the communication board, which was supposed to be accessible, was not present. A third resident, admitted with sepsis, dysphagia, and muscle weakness, was also found to require substantial assistance with personal hygiene. Observations revealed that this resident’s fingernails were dirty and crusted, with black fecal matter present under the nails. Staff acknowledged the poor condition of the resident’s nails and the need for regular cleaning, as outlined in facility policy. Facility policies reviewed by surveyors emphasized the importance of grooming, infection control, and resident dignity, but these were not followed in the care of these residents.
Failure to Follow Infection Control Protocols and Equipment Change Procedures
Penalty
Summary
Facility staff failed to consistently follow infection prevention and control measures as outlined in facility policy and procedure. Staff did not don full personal protective equipment (PPE), including gown and gloves, before entering contact isolation rooms for several residents with active or historical multidrug-resistant organism (MDRO) infections. Observations showed that staff entered rooms with posted contact precautions signage without wearing required PPE, and interviews confirmed that staff were aware of the expectations but did not always comply. The infection preventionist and quality assurance staff acknowledged that the entire room should be treated as contact isolation when any resident in the room is on such precautions, and that PPE must be donned prior to entry regardless of the intended activity inside the room. Additionally, the facility did not ensure that enhanced barrier precaution (EBP) signage and PPE supply carts were present and available for residents requiring EBP due to indwelling devices or colonization with MDROs. In one case, a resident with a history of ESBL and MRSA and an indwelling device did not have EBP signage or a PPE cart outside their room, contrary to facility policy and physician orders. The infection preventionist confirmed that EBP should have been initiated upon admission and maintained throughout the resident's stay, with appropriate signage and supplies in place. The facility also failed to follow protocols for changing respiratory equipment, such as oxygen tubing, nebulizer sets, and yankauers, for two residents. Equipment was observed to be dated several weeks prior, indicating it had not been changed weekly as required by physician orders and facility policy. The infection preventionist confirmed that the equipment should have been changed and properly stored to prevent contamination, and that failure to do so could result in preventable infections.
Failure to Maintain Resident Privacy and Provide Safe, Dignified Personal Items
Penalty
Summary
Staff failed to maintain privacy and dignity for two residents during care and daily living activities. In one instance, a resident with severe cognitive impairment and total dependence for personal care was observed receiving incontinent care with both the privacy curtain and room door left open, exposing the resident to view by others in the hallway. The CNA involved acknowledged not closing the curtain or door, and another CNA confirmed that privacy should be maintained during such care to prevent resident embarrassment. Review of facility policy confirmed the expectation to promote privacy and dignity during care, which was not followed in this case. In a separate incident, another resident with the capacity to make decisions was found with a water pitcher that had a cracked, chipped spout with sharp edges on their bedside table. The resident confirmed the condition of the pitcher, and staff interviews indicated that such items are not acceptable due to safety and dignity concerns. Facility policy requires that residents be treated with respect and dignity, including providing a safe environment and appropriate personal items, which was not ensured for this resident.
Failure to Ensure Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights placed within reach, as required by policy. For one resident with a history of falls, muscle spasms, and dementia, the call light was observed on the floor behind the bed and disconnected from the wall. The resident was unable to locate the call light and requested assistance. A CNA confirmed the call light was not accessible and stated it should have been within the resident's reach. The Assistant Director of Nursing also acknowledged the importance of call lights being accessible to residents. For another resident with diagnoses including type 2 diabetes, difficulty walking, and lack of coordination, the call light was also found on the floor and not within reach. The resident required partial to moderate assistance with daily activities. A CNA confirmed the call light was not accessible and acknowledged the risk of injury if the resident attempted to retrieve it. Review of the facility's policy indicated that residents should have access to a call system to request staff assistance.
Failure to Maintain Clean Side Rail Pads for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, insomnia, and dependence on supplemental oxygen was observed in bed with their face touching padded side rails that were visibly soiled with dry, yellow, and brown food stains. The resident's Minimum Data Set indicated moderately impaired cognitive skills and total dependence on staff for eating, toileting hygiene, and personal hygiene. During the observation, both the activity aide and a CNA confirmed that the side rail pads were dirty and acknowledged that the resident's face was in contact with the soiled pads while sleeping. Further interviews revealed that the facility's Quality Assurance Nurse stated side rail pads should be disinfected daily and as needed to prevent cross contamination and ensure resident safety and comfort. A review of the facility's infection prevention and control policy confirmed the requirement to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of disease and infection. The failure to keep the side rail pads clean resulted in an unsanitary environment and placed the resident at potential risk for infection.
Failure to Accurately Document Oxygen Therapy on MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's needs by not reflecting the resident's current oxygen therapy on the Minimum Data Set (MDS). The resident, who was admitted with diagnoses including dementia, epilepsy, aphasia, and dysphagia, had severely impaired cognitive skills and was dependent on staff for all activities of daily living. Despite having a physician's order for oxygen at two liters per minute via nasal cannula every shift, and documentation on the Medication Administration Record confirming daily administration of oxygen, the MDS did not indicate that the resident was receiving oxygen therapy. During interviews, the MDS nurse acknowledged that the omission was an error and stated that the resident's oxygen therapy should have been included in the MDS to accurately reflect the resident's respiratory treatment. The MDS Nurse Supervisor also confirmed the importance of the MDS as an accurate representation of the resident's assessments, care planning, treatments, and interventions. Review of facility policy indicated that the Resident Assessment Instrument (RAI) process is to be used as the basis for accurate assessment of each resident's functional capacity and health status.
Failure to Update Care Plan for Antipsychotic Medication Use
Penalty
Summary
The facility failed to develop or revise a comprehensive care plan for a resident who was prescribed Seroquel, an antipsychotic medication. The resident had multiple diagnoses, including bipolar disorder, major depressive disorder, difficulty walking, and a history of schizophrenia, as well as a diagnosis of dementia that was not reflected in the current admission record. The care plan for the use of Seroquel was not reviewed or updated to reflect the resident's current diagnoses or needs, and there was no documentation of nonpharmacological interventions to address the resident's behavioral and psychological symptoms. Interviews with facility staff and the psychiatrist revealed inconsistencies in the resident's diagnoses, with the psychiatrist unable to confirm schizophrenia and instead noting major depressive disorder and dementia as primary concerns. The facility's policy required individualized, updated care plans with specific interventions and goals for psychotropic medication use, but this was not followed. The lack of an updated care plan and nonpharmacological interventions placed the resident at risk for not receiving care tailored to their current condition and medication regimen.
Failure to Ensure Proper G-Tube Care and Infection Control
Penalty
Summary
The facility failed to provide proper care and treatment for gastrostomy tube (G-tube) management for two residents. For one resident with dementia, diabetes, and depression, the head of bed (HOB) was not elevated to the required 30 to 45 degrees during G-tube feeding, as specified in the physician's order and care plan. Observations showed the resident lying flat in bed while receiving tube feeding, and staff interviews confirmed that the HOB was not elevated as required. Facility policy also required the resident to be in a semi-Fowler's position during and after tube feeding. For another resident with dysphagia, diabetes, and anemia, the facility failed to maintain a clean valve on the G-tube. During observation, the valve was found to be dirty with black dry discoloration. Staff interviews confirmed that a dirty valve was not acceptable due to infection control concerns. It was also revealed that the facility did not have a policy or procedure in place for maintaining the cleanliness of the valve, despite having a general infection prevention and control program. Both deficiencies were identified through observation, record review, and staff interviews. The lack of adherence to physician orders, care plans, and infection control practices led to the findings for both residents.
Failure to Ensure Complete Dialysis Access Site Assessment and Documentation
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident receiving hemodialysis by not ensuring proper assessment and documentation of the resident's right upper arm arteriovenous (AV) shunt vascular access, as required by facility policy. Record reviews showed that the resident, who had end stage renal disease and was dependent on dialysis, had multiple instances where dialysis communication records from the dialysis center were incomplete. These records, covering several dates, lacked full documentation of the dialysis access site assessment, including checks for signs and symptoms of infection, and whether bruit and thrill were present. Interviews with the Assistant Directors of Nursing confirmed that the incomplete documentation could cause confusion in care delivery and that the receiving nursing staff should have contacted the dialysis center when records were incomplete. The facility's policy required regular written communication from the dialysis provider, including vital signs, pre- and post-dialysis weight, and any problems encountered, but this was not consistently documented for the resident in question.
Failure to Provide One-to-One Sitter for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services by not implementing a care plan intervention for a resident diagnosed with depression and suicidal ideation. The resident had a documented order and care plan for one-to-one sitter supervision following statements expressing a desire to die and refusal of medication. Despite this, on the night in question, there was no sitter present in the resident's room, as confirmed by multiple staff interviews and direct observation. Nursing notes and staff interviews indicated that the assigned staff were not aware of the sitter requirement, and the unit was short-staffed, with no additional personnel assigned to provide the required supervision. The facility's own policy required immediate one-to-one supervision for residents expressing suicidal ideation, and staff were obligated to report such statements to supervisors. However, the LVN on duty did not inform the RN supervisor about the lack of a sitter, and the Director of Staff Development could not provide documentation of staff assignment for the required supervision period. The Director of Nursing was also unaware of why the sitter was not assigned, despite the active order. This failure to implement the care plan and follow facility policy resulted in the resident not receiving the necessary behavioral health services as required.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's stated food preferences, specifically the dislike of pasta, as documented in the resident's care plan and dietary profile. Despite clear documentation that the resident did not want pasta and that the facility would honor food preferences, the resident was repeatedly served meals containing pasta or noodles, such as chicken noodle soup and a lunch tray with noodles. The resident expressed dissatisfaction with receiving these items and stated she would not eat them. Staff interviews revealed a lack of clarification regarding the resident's definition of pasta, with a CNA distinguishing between noodles and pasta, while the resident considered both to be the same. The Dietary Service Supervisor acknowledged that staff did not clarify the resident's preferences to ensure they were honored. The facility's policy required that resident preferences be reflected on tray cards and that the dietary department provide meals consistent with those preferences, but this was not followed in this case.
Failure to Accurately Document Oxygen Therapy Administration
Penalty
Summary
The facility failed to maintain accurate medical records for one resident by not properly documenting the administration of oxygen therapy. The resident, who had diagnoses including sepsis, dysphagia, muscle weakness, and COPD, had a physician's order for oxygen at 2 liters via nasal cannula as needed. However, during multiple observations and interviews, it was found that there was no oxygen set up or available at the resident's bedside, and several nurses confirmed that oxygen was not administered during the reviewed period. Despite this, the Medication Administration Record (MAR) indicated that oxygen was administered to the resident from the 1st to the 6th of the month. Multiple licensed nurses acknowledged that they did not administer the oxygen, yet the MAR reflected otherwise, indicating inaccurate documentation by at least six licensed nurses. The facility's policy requires nursing documentation to be concise, clear, pertinent, and accurate, which was not followed in this instance.
Arbitration Agreement Lacks Required Information on Neutral Arbitrator and Venue
Penalty
Summary
The facility failed to ensure that its arbitration agreement, as signed by a resident, included information regarding the use of a neutral arbitrator and the selection of a venue convenient to both parties, as required by federal regulations and the facility's own policy. During review, it was found that the arbitration agreement signed by a resident did not contain these provisions. The Resident Ambassador, who explained the agreement to the resident, stated that she only read what was included in the document and did not provide information about a neutral arbitrator or convenient venue, as this information was not present in the form and she was unaware it was necessary. The Admissions Director confirmed that the facility had recently adopted a shortened version of the arbitration agreement and was not aware that it needed to include language about a neutral arbitrator and convenient venue. The facility's policy indicated that the arbitration agreement should comply with federal and state laws, and that the administrator or designee is responsible for ensuring the use of the latest compliant version. This omission resulted in an incomplete understanding of the arbitration agreement for the resident involved.
Failure to Maintain Safe and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, sanitary, and home-like environment for two of five sampled residents by not addressing exposed electrical wiring and overflowing trash cans. For one resident with diagnoses including diabetes mellitus, anemia, hemiplegia, and hemiparesis, surveyors observed exposed wires on the bed control in the resident's room. Both a CNA and an LVN confirmed the presence of the exposed wires and acknowledged that this was unacceptable and dangerous. Another resident, with a history of hypertension, diabetes mellitus, and anemia, was found to have exposed call light wires in their room. An LVN confirmed the exposed wires and stated this placed the resident at risk for accident. Additionally, in one resident room, the trash can was observed to be open and overflowing with used PPE. A registered nurse stated that trash cans were supposed to be closed at all times, and that exposed wiring was not acceptable as it could harm residents and staff. Review of the facility's policies and procedures indicated requirements for maintaining a safe, clean, and comfortable environment, which staff acknowledged were not followed in these instances.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as required by its Abuse Prevention and Prohibition Program. One resident with severe cognitive impairment and behavioral issues, including hallucinations and a history of behavioral problems, tipped over the wheelchair of another resident who also had severe cognitive impairment and physical limitations due to Parkinson's Disease and dementia. This incident occurred while the resident was being wheeled toward the dining room, resulting in the other resident falling and hitting her head on a doorway, causing a minor skin tear and bleeding. Staff observations and interviews confirmed that the incident was witnessed by a CNA, and documentation indicated that the resident who caused the incident was not adequately monitored to prevent such behavior. The facility's policy states that all residents have the right to be free from abuse and that the facility is responsible for protecting residents from abuse by anyone. The DON acknowledged that the resident was not monitored sufficiently to prevent the incident, which resulted in physical harm to another resident.
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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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