Santa Monica Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 1338 20th Street, Santa Monica, California 90404
- CMS Provider Number
- 555808
- Inspections on file
- 124
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Santa Monica Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not maintain clean and sanitary ventilation intake screens in resident rooms, as evidenced by thick dust accumulation on intake screens located above the beds of two residents. One resident reported the dust had been present for a long time and was concerned about inhaling it, while another resident, in the facility for several years, stated he had never seen the screens cleaned. The Maintenance Supervisor confirmed the presence of dust on an intake screen in another room and acknowledged the potential for allergen exposure, despite a facility policy requiring a safe, clean, and sanitary homelike environment.
Surveyors found that resident food storage practices did not follow facility P&P in multiple nutrition rooms. On two floors, open dry food items such as cereal and chips were stored in cabinets without labels or dates, and multiple bags and containers of resident food in refrigerators lacked required resident names, received dates, and open dates. Refrigerators were also overcrowded, limiting air circulation, despite posted instructions that all resident food must be labeled with name, date, expiration date, and discarded after 72 hours, and a written P&P requiring proper coverage, dating, labeling, and avoidance of overcrowding.
Staff failed to respect two English-speaking residents’ rights to dignity and communication when staff spoke to each other in a foreign language while providing care. Both residents had documented English as their primary language and required varying levels of assistance with ADLs and bed mobility; one had intact cognition and the other had mild memory problems. Each resident reported hearing staff speak in a language they did not understand during care, with one expressing concern that staff could be talking about her. A CNA acknowledged that staff should not speak a different language than the one the resident speaks, and the facility’s Resident Rights policy requires employees to treat residents with kindness, respect, and dignity and to support them in exercising their rights.
A resident with encephalopathy, Parkinson’s disease, epilepsy, schizophrenia, documented impaired decision-making capacity, and memory problems was assessed as being at risk for elopement and had a care plan calling for a Wanderguard bracelet, frequent visual checks, and staff awareness of elopement risk. A nurse obtained a physician order for a Wanderguard and attempted to obtain consent from the resident’s representative, but follow-up was left to the next shift and not completed. No order for Wanderguard use or monitoring of wandering behaviors was entered, and no related monitoring or documentation occurred. The resident subsequently eloped, demonstrating that the facility did not implement the care-planned interventions for wandering risk.
Staff failed to follow facility linen-handling policies and infection control practices. An in-service on proper linen handling required storing clean linen in designated clean areas or carts, keeping it covered during transport, and only bringing needed amounts into each room, but one CNA was not listed as having attended. A resident with multiple serious conditions and total dependence on staff had a large open plastic bag of mixed clean linen items stored on the nightstand, which a CNA used as a central supply for all assigned residents by transferring linen from that bag into other rooms. Another CNA described handling linen separately for each resident, while an LVN stated CNAs were educated to keep separate linen bags in each room and acknowledged that linen brought into a room is considered dirty. Surveyors also observed two linen carts with covers flipped up, leaving clean linen exposed, contrary to policy requiring clean linen to be protected from environmental contamination.
Staff failed to follow facility policy for assisting with in-room meals for three cognitively impaired residents who required varying levels of help with eating. One resident with metabolic encephalopathy, dementia, and total dependence for eating was found lying flat in bed with food in the mouth and on the linens while the meal tray remained mostly untouched and covered; the assigned CNA had been redirected to the dining room to assist two other residents needing feeding help and did not promptly return. For all three residents, care plans required documentation of PO intake at every meal, but intake records for the cited day showed either no intake data or "resident not available," and the CNA did not report decreased intake to an LVN as expected. Interviews revealed that usual restorative nursing assistant coverage in the dining room was absent that day, CNAs were managing multiple feeder residents, and charge nurse supervision did not ensure that feeding assistance and intake documentation were completed according to policy.
A resident with schizophrenia, bipolar disorder, severe cognitive impairment, and documented medical noncompliance repeatedly refused ordered Depakote and risperidone over multiple days, including several stretches of three or more consecutive refusals. The care plan required notifying the physician of risks related to non-compliance, and facility policy required physician notification and documentation when consecutive doses of vital medications were refused. Review of the MAR and nursing notes, along with interviews with an LVN and the DON, showed that no physician notification or response was documented despite these repeated refusals, resulting in a significant medication error.
A resident with ESRD and dependence on hemodialysis, along with other serious comorbidities, had physician orders for thrice-weekly dialysis with specified chair times and transportation schedules. The resident’s care plan and clinical documentation show that multiple dialysis sessions were missed because transportation either did not arrive or would arrive too late, and on one occasion due to an expired PCS form that had not been timely completed and signed, which was required for insurance-authorized transport. Staff interviews confirmed that social services relied on PCS-based insurance transportation, that some contracted transportation companies failed to show without warning, and that nursing staff coordinated orders and transportation with social services, yet these processes did not prevent the resident from missing several medically necessary dialysis appointments despite facility policies stating that social services would help obtain transportation and assist in arranging appointments.
A resident with a history of cerebral infarction, aphasia, hemiplegia, and hemiparesis, but no documented cognitive impairment, and the resident’s POA were not provided with required written notices of Medicaid/Medicare coverage, share of cost (SOC), or monthly billing statements. Due to ownership changes and high turnover in the business office and social services, the facility did not update records or send periodic SOC notifications, and the business office could not verify that any monthly statements or SOC notices had been mailed. The POA reported never receiving statements or SOC information and only learned of four months of unpaid SOC when contacted by a third‑party company, despite facility policy requiring monthly itemized billing and written notice before changes in non‑covered costs.
Staff failed to follow hand hygiene standards when two CNAs fed a dependent, cognitively impaired resident with multiple diagnoses, including anoxic brain damage, UTI, immune disorder, and heart failure. One CNA placed a bed remote on the floor, then on the bed without cleaning it, and proceeded to feed the resident without hand hygiene; another CNA entered from the hallway and began to feed the resident without hand hygiene. Both CNAs acknowledged not performing hand hygiene, while the ADON and IP confirmed that hand hygiene is a required standard precaution per facility policy and CDC-based infection prevention guidelines.
Surveyors found that the facility did not develop required discharge care plans for three cognitively intact residents with multiple comorbidities, including fractures, OA, morbid obesity, DM, dysphagia, and serious mental health conditions. Each resident required extensive or total assistance with toileting, bathing, and transfers, yet no discharge care plans were present in their records. The DSS reported that discharge planning is supposed to begin at admission and be updated regularly, while the MRA confirmed that no discharge care plans existed for these residents.
The facility did not report an allegation of verbal and physical abuse between two residents to the appropriate authorities within the required two-hour timeframe, despite being aware of the incident and having a policy mandating immediate reporting. Both residents had significant medical conditions and required staff assistance, and the delay in reporting was confirmed through staff interviews and record review.
The facility did not ensure that the Social Services Director assessed or documented the psychosocial well-being of several residents following incidents of alleged physical and verbal abuse. Despite incidents involving law enforcement and staff-witnessed verbal altercations, affected residents did not receive required follow-up or support, and the lack of documentation was confirmed by staff interviews. This failure was inconsistent with facility policy and job expectations.
Two residents with significant mobility and health needs experienced repeated delays in staff response to their call lights, contrary to facility policy. Both residents reported waiting extended periods for assistance, leading to discomfort and feelings of neglect. Staff interviews confirmed that delayed responses were common, especially during shift changes or when staffing was reduced.
A resident with severe psychiatric conditions and identified as an elopement risk was able to leave the facility without staff notification. Documentation regarding the resident's intent to leave AMA was incomplete, and staff were not consistently monitoring resident whereabouts, especially during shift changes. The resident's absence was discovered during rounds, and their whereabouts remain unknown.
Maintenance staff did not report nonfunctioning thermostats or temperature regulation issues to administration, resulting in the air conditioning being turned off at night and residents experiencing excessive heat. Despite multiple residents with complex medical needs complaining about the temperature, staff failed to offer available portable AC units or follow facility policy for reporting and documentation.
Two residents with significant mobility impairments and intact cognition were forcefully removed from their motorized power wheelchairs by corporate staff, placed into manual wheelchairs without consent or clinical justification, and denied access to their preferred mobility devices. The residents experienced emotional distress, loss of autonomy, and were confined to bed for extended periods, resulting in psychosocial harm.
The facility did not keep the phone ringers at an audible volume at all nursing stations, resulting in staff being unaware of incoming calls until overhead pages were made. LVNs confirmed the phone volumes were turned down, and calls from doctors, family, and patients could not be promptly answered, contrary to facility policy.
A resident with multiple chronic conditions did not receive IV fluids as ordered, with the infusion not running for an extended period and staff unaware of the order. The IV bag remained partially full and uninfused, and the nurse supervisor had not remembered the order, contrary to facility policy requiring proper administration and monitoring of IV therapy.
A resident with multiple complex medical conditions was admitted without the admission agreement being explained or signed at the time of admission, as required by facility policy. The resident's representative did not receive the admission packet until weeks later and experienced delays in getting questions answered about the agreement, resulting in a lack of clarity regarding covered services and payment responsibilities.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents were involved in an altercation when one, with a history of wandering and cognitive impairment, entered another's room and accessed personal belongings, leading to the second resident throwing water at the first. Although the incident was documented, staff and administration did not investigate or report the event to required authorities as mandated by facility policy and federal regulations.
A resident with severe cognitive impairment and multiple respiratory conditions did not receive BiPAP therapy as ordered, with compliance reports showing significantly reduced usage time. Staff interviews revealed ongoing issues with the BiPAP machine leaking and alarming at night, and the device was not consistently set up or functioning properly, resulting in the resident not receiving the prescribed respiratory support.
Nursing staff failed to respond promptly to a resident's call light, left a resident in discomfort for an extended period, and did not ensure that registry CNAs were competent in required care skills. Some CNAs lacked proper orientation, did not wear ID badges, and had communication barriers with residents. The facility also lacked a Director of Staff Development to oversee staff training, and competency documentation for registry CNAs was incomplete or missing.
Six residents with physician orders for PT evaluation and treatment did not receive timely assessments due to the facility's lack of a consistent, qualified PT. Staff interviews confirmed that PT evaluations were delayed or missed, with agency PTs only available intermittently. Residents with significant mobility impairments and complex medical needs were left without appropriate rehabilitative services, contrary to facility policy and physician orders.
The facility did not consistently open the dining room for dinner, limiting residents' ability to choose where to eat. Staff interviews confirmed that the dining room was typically only available for lunch, and a resident reported having to eat dinner in his room due to lack of staff support. This practice violated facility policy and residents' rights to self-determination and choice.
The facility did not provide enough nursing staff to keep the dining room open for all meals, resulting in residents only being able to eat lunch in the dining room while breakfast and dinner were served in their rooms. Staff interviews and assignment records confirmed ongoing staffing shortages, and a resident with significant medical needs reported being unable to eat dinner in the dining room due to lack of staff. The DON acknowledged the issue after being informed by the activity director.
A resident with severe cognitive and physical impairments was allegedly pushed from bed by a CNA during ADL care, as reported by a roommate. Despite the allegation, the CNA continued working on the same floor, and the incident was not reported to all required agencies or fully documented according to facility policy. The facility did not submit the investigation findings within the required timeframe, resulting in delayed external review.
The facility did not have a full-time PT on staff after the previous PT resigned, leaving residents with physician-ordered physical therapy without access to these services. Both the OT and DON confirmed that no PT was available, and facility policy requires that specialized rehabilitative services, including PT, be provided by qualified personnel.
A facility with over 120 beds did not have a qualified full-time social worker on staff, as the SSD was absent for an extended period and the SSA, who lacked the required education and experience, assumed the role. A resident with significant medical needs had not met with the SSD since readmission and had not participated in a care plan meeting, contrary to facility policy.
A resident with multiple chronic conditions who required significant assistance with daily activities was left waiting for over 30 minutes after activating the call light for help with personal care. The call light was observed blinking and audible at the nursing station, but staff did not respond promptly, as the CNA was assisting another resident and the LVN only responded after the delay. Facility policy and staff interviews confirmed that call lights should be answered immediately.
A CNA transferred a resident with significant mobility limitations using a mechanical Hoyer lift without the required second staff member, contrary to facility policy and the resident's care plan. The resident, who was fully dependent for ADLs and had multiple medical conditions, was placed at risk due to this action, as confirmed by interviews with the LVN and DON.
A resident with cognitive impairment and multiple medical conditions was allegedly subjected to verbal abuse by a CNA, who reportedly called the resident 'crazy' during an overnight shift. Although the incident was documented and discussed among staff, the required report to public health authorities was not made within the mandated two-hour window, resulting in a delay in external notification.
A resident dependent on staff for care, with multiple medical conditions, experienced ongoing verbal abuse and controlling behavior from her roommate, including being blocked from exiting the room and subjected to derogatory remarks. Despite repeated reports to staff and documentation of the incidents by a CNA, SSA, and RN, the facility did not implement effective interventions beyond offering room changes, which both residents refused. Leadership remained unaware or did not act further, resulting in continued risk of abuse.
A resident with a history of liver transplant and multiple complex medical conditions did not have a care plan addressing the liver transplant. The DON confirmed the absence of this care plan during record review, despite facility policy requiring comprehensive, person-centered care plans for all residents.
A resident with severe cognitive impairment and high elopement risk was not properly identified with an ID wristband, and staff were not informed of the resident's elopement risk or the purpose of the Wanderguard device. The resident was not listed on the CNA assignment sheet, and the CNA caring for the resident was unaware of critical safety information, resulting in a failure to meet professional standards of quality.
A resident with cognitive impairment and multiple diagnoses had a skin tear on the right wrist/hand that was not treated according to physician's orders, which required cleansing, application of xeroform, and covering with a dry dressing. During observation, the wound was left open to air without a dressing, and the LVN was unaware of the required treatment. The DON confirmed that physician's orders should be followed if present.
A resident with severe cognitive impairment and a history of elopement was not properly identified or communicated as an elopement risk to staff. The resident was not listed on the CNA assignment sheet, staff were unaware of the Wanderguard's purpose, and the resident was observed without an ID wristband, all in violation of facility policy and safety protocols.
A resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls resulting in injuries, including a hip fracture requiring surgery. Despite being identified as a fall risk and having a care plan with specific interventions, staff did not consistently implement or revise these interventions after each fall. Environmental hazards, such as urine on the floor and an out-of-reach call light, were present, and staff did not provide the required level of supervision, contributing to the resident's repeated falls and injuries.
Facility staff did not notify the physician or document a change of condition when a resident with multiple chronic conditions complained of a sore throat, swallowing issues, and body itching, despite later testing positive for Pertussis. Staff interviews and record reviews confirmed that required documentation and notification protocols were not followed.
A resident with multiple chronic conditions and severe cognitive impairment had grievances raised by a family member regarding lack of activities and poor communication from staff. Although these concerns were noted in progress notes, the facility did not document or investigate the grievances as required by policy, and the DON confirmed the absence of proper grievance documentation.
Two residents with severe cognitive impairment did not have their personal belongings properly inventoried or returned upon admission, discharge, or transfer. The facility failed to document inventories and obtain required signatures, resulting in missing or unreturned items, as confirmed by the DON.
A resident with multiple chronic conditions and cognitive impairment was admitted without a baseline care plan being developed and implemented within 48 hours, as required. The initial care plans for falls, allergies, pain, and skin integrity were not started until several days after admission, and this delay was confirmed by the DON and facility records.
The facility failed to accommodate the needs and preferences of four residents by not ensuring operational televisions and consistent hot water availability. Several residents reported non-functional TVs for three days, affecting their ability to watch programs. Additionally, issues with hot water availability during showers were reported, with one resident having to shower early to avoid running out of hot water and another expressing reluctance to shower due to cold water. Interviews with staff revealed awareness of these issues, but the facility did not adhere to its policy of accommodating resident needs.
A resident with conditions including spinal stenosis, obesity, and COPD received an opened letter, violating their right to privacy. The facility's Nursing Consultant confirmed that mail should remain unopened, as supported by the facility's policies and the California Standard Admission Agreement for Skilled Nursing Facilities.
A resident with a fracture and low back pain experienced a delay of over one and a half hours in response to a call light request for ice chips. The facility's policy requires immediate response to call lights, but insufficient staffing led to this delay, potentially affecting the resident's quality of life.
The facility did not appoint a licensed administrator as required by the Governing Board, potentially affecting resident care and facility management. The Acting Administrator's license was not posted because he was not appointed due to exceeding the 200-bed supervision limit. Facility policies state that the administrator should be appointed by the governing board and is responsible for daily operations.
The facility did not appoint a licensed administrator as required by the governing board, as observed by the absence of an administrator license on the consumer bulletin board. The Acting Administrator admitted he was not appointed due to exceeding the 200-bed supervision limit. Facility policies state the administrator must be appointed by the governing board and manage daily operations.
The facility failed to maintain proper infection control practices, including improper storage of personal items in the kitchen, inadequate hand hygiene by staff, and improper handling of medical equipment. Staff were also observed wearing N95 masks incorrectly during an influenza outbreak, increasing the risk of infection spread among residents.
The facility failed to maintain accurate and current advance directives for four residents, leading to potential conflicts with their healthcare wishes. Despite the residents' varying cognitive impairments and medical conditions, their advance directives were not documented in their records. Interviews with staff revealed inconsistencies in the process of obtaining and documenting these directives, highlighting a deficiency in the facility's protocol.
Failure to Maintain Clean Ventilation Intake Screens in Resident Rooms
Penalty
Summary
The facility failed to maintain clean and sanitary ventilation intake screens in resident rooms, resulting in thick dust accumulation on the intake screens above the beds of two sampled residents. During an observation in one resident’s room, the ventilation intake screen above the foot of her bed was covered with a thick layer of dust, which the resident confirmed had been present for quite a while and expressed concern about dust potentially falling on her and being inhaled. In another resident’s room, the intake screen above the foot of his bed was also observed with a layer of dust; this resident, who had been at the facility for four years, stated he had never seen anyone clean it. The Maintenance Supervisor observed a similar dust layer on a ventilation intake screen in another room and acknowledged that this condition could expose residents to allergens. These conditions occurred despite the facility’s policy and procedure titled “Homelike Environment,” which states that residents are to be provided with a safe, clean, comfortable, and homelike environment and that staff and management will maximize a clean, sanitary, and orderly environment.
Failure to Label, Date, and Properly Store Resident Food in Nutrition Room Refrigerators
Penalty
Summary
The deficiency involves failure to follow the facility’s P&P for resident refrigerator/freezer storage and food handling in resident nutrition rooms. During an observation and concurrent interview with the Infection Preventionist Nurse (IPN) in the 2nd floor nutrition room, surveyors observed an undated and unlabeled open box of cornflakes and an undated and unlabeled open bag of potato chips stored in a cabinet. The IPN acknowledged these items should not have been stored there in that condition and stated they should have been labeled with the resident’s name and an expiration date, and that everything should have a name and an open date. Further observation in the same 2nd floor nutrition room revealed a variety of bags inside the resident refrigerator that were not appropriately labeled and dated. The IPN verified that the food in the refrigerator should be labeled with the resident’s name and an open date so staff know when to discard it, and stated that they clean it out every three days. In the 3rd floor nutrition room, the resident refrigerator contained an opened plastic to-go container with no resident name or received date, along with various bags of food without proper dates and crowded in the refrigerator, despite a posted sign instructing that all resident food be labeled with name, date, and expiration date and that unlabeled food or food left more than 72 hours would be discarded. Review of the facility’s P&P for Resident’s Refrigerator/Freezer Storage – Dietary Services showed requirements that food items be stored to allow air circulation, avoid overcrowding, not be stored beyond 72 hours from date received, and that all items be properly covered, dated, and labeled with delivery and open dates, which were not followed in these observations.
Failure to Respect English-Speaking Residents’ Communication and Dignity Rights
Penalty
Summary
The deficiency involves staff failing to honor residents' rights to dignity, self-determination, communication, and use of their primary language during care. For Resident 3, the Admission Record dated 3/24/26 showed admission with HTN, anemia, hemiplegia and hemiparesis following a stroke, and identified English as the primary language. An MDS dated 2/18/26 documented intact cognition and a need for supervision, touching assistance, or substantial/maximal assistance with ADLs and bed mobility. During interview, Resident 3 stated she hears everything and has heard staff speaking in other languages among themselves. Resident 5’s Admission Record dated 3/24/26 documented admission with muscle weakness, osteoarthritis of the knee, asthma, spinal stenosis, and lymphedema, and identified English as the primary language. An MDS indicated mild memory problems, a need for set-up or clean-up assistance with eating, and substantial/maximal assistance to dependence for other ADLs and bed mobility. During interview, Resident 5 reported that two staff members were in her room that morning speaking a foreign language to each other, and stated she only speaks English and does not know what they are saying and that they could be talking about her. A CNA interviewed stated staff should not be speaking a different language with each other that is different from the one the resident speaks. The facility’s Resident Rights policy, reviewed 6/2/25, stated employees shall treat all residents with kindness, respect, and dignity and support residents in exercising their rights, including the right to be treated with respect.
Failure to Implement Wandering Care Plan Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to follow an established care plan for a resident identified as being at risk for wandering and elopement, which resulted in an elopement incident. The resident had multiple diagnoses, including encephalopathy, Parkinson’s disease, epilepsy, schizophrenia, and anemia, and the History and Physical documented that the resident did not have the capacity to understand and make decisions. An MDS assessment indicated short- and long-term memory problems, with the resident requiring varying levels of assistance for ADLs. An Elopement Risk Evaluation dated 3/8/26 identified the resident as at risk for elopement, with comments specifying use of a Wanderguard and frequent visual checks. A wandering risk care plan initiated the same day included interventions such as a bracelet alarm for alarmed doors, checking the resident’s location every 30 minutes, and ensuring all staff were aware of the elopement risk. Despite these identified risks and care plan interventions, the facility did not implement the ordered Wanderguard or ensure monitoring consistent with the care plan prior to the elopement. A registered nurse supervisor reported receiving a physician’s order for a Wanderguard and, because the resident could not consent, contacting the resident representative for consent and endorsing follow-up to the next shift. Progress notes for the following day showed no evidence that any shift followed up on obtaining consent or implementing the Wanderguard before the resident eloped in the early morning hours of 3/10/26. A LVN confirmed that there was no order in the order summary for monitoring a Wanderguard or wandering behaviors through 3/17/26, and therefore no related documentation or monitoring occurred. The facility’s own wandering and elopement policy stated that residents at risk would have care plans including strategies and interventions to maintain safety, but the documented interventions were not carried out for this resident.
Improper Linen Handling and Storage Breaching Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to handle and store clean linen in accordance with its infection prevention and control policies and its in-service training on proper linen handling. An anonymous complaint was received alleging insufficient linen and blankets. During review of an in-service titled “Proper handling of Linen,” the facility’s guidance stated that clean linen should be stored in a designated clean area or cart, kept covered when transported to a patient room, and that only the amount of linen needed for each resident should be brought to the room. The sign-in sheet for this in-service did not include the name of CNA 1. The facility’s Laundry and Linen policy required separation of soiled and clean linen at all times and protection of clean linen from environmental contamination by covering clean linen carts. During observation and interview in a resident room, surveyors noted a large, open plastic bag filled with multiple bed pads, gowns, towels, and sheets placed on the nightstand next to the bed of a female resident with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, DM, metabolic encephalopathy, CKD stage 4, dementia, muscle weakness, and polyneuropathies. This resident’s MDS showed impaired cognition and total dependence on staff for toileting, showering, bathing, and transfers. CNA 1 stated that the resident had already received a bed bath and explained that she gathered all linen for all of her residents in the morning, placed it in one bag, brought that bag into this resident’s room, and then used that bag as a source of linen for other residents by transferring items into separate plastic bags. CNA 1 stated this was common practice. Another CNA reported gathering linen for each resident separately and placing each bag in the respective resident’s closet for infection control. An LVN stated CNAs were educated to gather linens in a plastic bag and place them inside each resident’s room so each resident would have their own separate bag, and acknowledged that having all linen for every resident in one room could lead to cross contamination because once linen is taken into a room it is considered dirty. Additionally, on a separate floor, two linen carts were observed with their covers flipped up, leaving clean linen exposed, contrary to the facility’s policy to keep clean linen hygienically clean and protected from environmental contamination.
Failure to Provide and Document Required Feeding Assistance and Intake Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedures for assisting residents with in-room meals, including providing needed feeding assistance, documenting meal intake, and ensuring appropriate reporting of decreased intake. For three cognitively impaired residents with significant functional limitations, staff did not consistently assist with feeding as required by their assessments and care plans, nor did they document meal intake percentages as directed. The facility also failed to ensure that a CNA notified licensed nursing staff when a resident had decreased meal intake. Resident 1 was admitted with multiple diagnoses including metabolic encephalopathy, dementia, diabetes, muscle weakness, anemia, hypertension, a pressure ulcer, and GERD. The MDS showed cognition was not intact and that Resident 1 required maximal assistance with eating and was dependent for toileting, showering, and transfers. A nutrition assessment indicated total assistance was required for eating, and the care plan identified decreased self-feeding abilities related to metabolic encephalopathy and dementia, as well as nutritional risk with an intervention to document PO intake at every meal. On observation, Resident 1 was found lying flat in bed with eyes closed, chewing with orange material in the mouth and on the lips, and a half-eaten piece of potato on the sheet next to the face. The meal tray was on the bedside table with the cover still on; the plate contained mostly uneaten food and an unopened juice. CNA 1, who was assigned to Resident 1 and stated this was the first time caring for this resident, did not begin feeding until later, after being redirected to assist other residents in the dining room, and there was no documentation of meal intake for Resident 1 on the cited date, nor evidence that decreased intake was reported to an LVN. Resident 3 had diagnoses including right-sided hemiplegia/hemiparesis, encephalopathy, UTI, COPD, diabetes, muscle weakness, aphasia, dysphagia, hyperlipidemia, anxiety disorder, and hypothyroidism, with an MDS indicating cognition was not intact and that supervision or touch assistance was required with eating. The care plan identified nutritional risk with an intervention to document PO intake at every meal, and a physician order specified a fortified regular pureed diet, level 4 texture, thin consistency, and that the resident was a feeder. Meal intake documentation for the referenced date showed “resident not available.” Resident 4, with hemiplegia/hemiparesis after cerebral infarction, asthma, epilepsy, protein-calorie malnutrition, muscle weakness, dysphagia, UTI, aphasia, hyperlipidemia, and hypertension, also had impaired cognition and required moderate assistance with eating. The care plan for Resident 4 included documenting PO intake at every meal, yet the same date’s intake record also indicated “resident not available.” Interviews revealed that CNA 1 was simultaneously assigned to Residents 1, 3, and 4 and was pulled to the dining room to assist Residents 3 and 4 when no restorative nursing assistants were present, leaving Resident 1 without timely feeding assistance and contributing to the lack of proper intake documentation and reporting for all three residents. Staff interviews further clarified the breakdown in supervision and adherence to policy. CNA 1 reported starting to feed Resident 1 but being told to go to the dining room to assist Residents 3 and 4, who also needed feeding assistance, and only returning later to finish feeding Resident 1. LVN 1 confirmed that Resident 1 required assistance with feeding and stated that CNA 1 did not request help or report any decreased intake, despite the expectation that CNAs report intake of less than 50% and complete a “stop and watch” form. The RNA stated that there are usually three RNAs assigned to the dining area to pass trays and feed residents, but on the day in question one RNA had called off and the remaining RNA was sent out with another resident to an appointment and did not return until mid-afternoon, leaving the dining room without RNA coverage. LVN 2 observed there were no RNAs in the dining room and that CNAs were taking residents back to their rooms. The ADON later explained that one RNA had called off and the other was at an appointment, and that charge nurses were expected to monitor whether residents needing feeding assistance were being helped and to supervise CNAs, including adjusting assignments when a CNA had multiple residents requiring feeding assistance. Despite these expectations and the written policy on assisting residents with in-room meals and documenting intake, the facility did not ensure that Residents 1, 3, and 4 were assisted with feeding as care planned, that their meal intake percentages were documented, or that decreased intake for Resident 1 was reported to licensed nursing staff. The facility’s written policy on assisting residents with in-room meals required staff to review the resident’s care plan, ensure appropriate positioning and preparation for meals, assist residents as necessary while encouraging self-feeding, and document the date and time of the procedure, the staff involved, the percentage of the meal consumed, the resident’s participation, and any special requests. Observations and record reviews showed that these steps were not followed for the three residents on the date in question. Resident 1 was not positioned upright as specified in the policy when first observed with food in the mouth and on the bed, and the tray remained covered and largely uneaten until CNA 1 returned. For Residents 1, 3, and 4, the required documentation of meal intake percentages was either missing or recorded as “resident not available,” and there was no evidence that CNA 1 notified an LVN or RN of Resident 1’s decreased intake, contrary to facility expectations and the care plan interventions. These combined observations, interviews, and record reviews demonstrate that the facility did not implement its own policy and procedures for assisting residents with in-room meals and did not ensure that residents were assessed and supported appropriately for feeding assistance, that meal intake was documented as care planned, or that decreased intake was reported to licensed staff for further evaluation.
Failure to Notify Physician After Repeated Refusal of Vital Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure a resident was free from significant medication errors by not notifying the physician after repeated refusals of vital psychotropic medications. The resident had documented diagnoses of schizophrenia, bipolar disorder, history of alcohol abuse, medical noncompliance, and severely impaired cognition. Multiple clinical documents, including the history and physical, psychiatry evaluations, and physician progress notes, indicated the resident lacked capacity to make medical decisions, had a history of refusing care, and was being treated with Depakote for bipolar disorder and risperidone for paranoid schizophrenia. Review of the resident’s care plan showed a problem for altered behavior patterns related to schizophrenia and psychotropic medication use, with an intervention to notify the physician of any risk or consequences related to non-compliance. The physician’s orders included Depakote 500 mg, two tablets at bedtime for bipolar disorder, and risperidone 3 mg every 12 hours for paranoid schizophrenia. Review of the Medication Administration Record for the month showed that Depakote doses were refused on nine occasions and risperidone doses were refused multiple times for both morning and evening administrations over the review period, including several instances of refusals on three or more consecutive days. Interviews with an LVN and the DON confirmed that facility policy titled “Preparation and General Guidelines” required physician notification when consecutive doses of a vital medication were refused, and that nursing staff were to document the notification and the physician’s response. The LVN stated that if the resident refused Depakote and risperidone for at least three consecutive days, the physician should be notified and the response documented. The DON, upon review of nursing progress notes for the same period, stated that there was no documentation showing that a physician had been notified about the resident’s repeated refusals of Depakote and risperidone. The DON further acknowledged that without such notification, the physician would assume medications were being administered and would not know what other interventions to order, confirming that the required notification and documentation did not occur.
Missed Dialysis Treatments Due to Failed Transportation Arrangements
Penalty
Summary
The deficiency involves the facility’s failure to ensure reliable transportation for a resident who required thrice-weekly hemodialysis, resulting in multiple missed treatments. The resident had diagnoses including pulmonary hypertension, type 2 diabetes mellitus, end stage renal disease with dependence on renal dialysis, and required assistance with transfers. Physician orders specified dialysis on Tuesday, Thursday, and Saturday with set chair times and transportation pick-up and return times. The care plan documented that the resident missed dialysis appointments on two occasions due to transportation issues, and progress notes and SBAR forms showed that on three separate dates the resident missed scheduled dialysis because transportation either did not arrive or would arrive too late for the appointment. On at least one occasion, the missed dialysis was attributed to an expired Physician Certification Statement (PCS) form that had not been timely completed and signed by the primary physician, which was required by the resident’s insurance to authorize transportation. Interviews with staff further described the actions and inactions that led to the deficiency. The social services director stated that one missed dialysis treatment occurred because the PCS form had expired and was not completed in a timely manner by the primary physician, and that other missed treatments were due to the contracted insurance transportation not showing up on time. The social services director acknowledged that the resident’s insurance provided transportation based on the PCS certification. The RN supervisor confirmed awareness of at least one missed dialysis treatment and explained that RNs and LVNs process physician orders and work with social services for transportation, noting that some transportation companies fail to show up without warning. The DON stated that the resident had missed a dialysis treatment because transportation did not show. Facility policies on Transportation and Appointments indicated that social services would help residents obtain transportation and that the facility would assist in scheduling appointments and arranging necessary transportation, but the documented events show that these processes did not prevent the resident from missing multiple medically necessary dialysis sessions.
Failure to Provide Required SOC and Coverage Notices to Resident and POA
Penalty
Summary
The facility failed to provide required written notice of Medicaid/Medicare coverage, share of cost (SOC), and related financial obligations to a resident and the resident’s responsible party/POA. The resident, who had diagnoses including aphasia following cerebral infarction, hemiplegia, and hemiparesis, was assessed as having no cognitive impairment on an MDS dated 11/18/2025 and reported that their son was the responsible party/POA. The resident stated that while in the facility they were not provided any financial documents and no one from the facility discussed monthly billing for services. About a week prior to the interview, the resident learned from the responsible party/POA that payments were behind for the past four months. The social services director reported that due to ownership changes and high turnover in the business office and social services staff during 2025, some residents’ records had not been updated and some residents with SOC had not yet been notified, even though the business office was responsible for updating and notifying residents and responsible parties. The business office manager stated that residents with SOC are usually identified at pre‑admission, admission, and periodically, and that Resident 2’s responsible party/POA should have received monthly statements and paid the SOC that began in September 2025. However, the business office manager could not verify whether monthly statements or SOC notifications had been mailed to the resident or responsible party and acknowledged that past‑due bill notifications should come from the business office, not from a third‑party company. The responsible party/POA confirmed not receiving monthly statements, not knowing the SOC amount, and only becoming aware of four months of past‑due bills after a collection call from a third‑party company. The facility’s billing policy required monthly resident billing with itemized non‑covered services and written notification at least 60 days prior to changes in the cost of non‑covered items and services.
Failure to Perform Hand Hygiene Before Resident Feeding
Penalty
Summary
Facility staff failed to perform required hand hygiene while providing care to one of seven sampled residents, resulting in a deficiency in the infection prevention and control program. During a tour, CNA 3 was observed assisting a resident in a shared room by using the bed remote, placing the remote on the floor, then picking it up and placing it on the resident’s bed without cleaning it. CNA 3 then proceeded to feed the resident without performing hand hygiene. In a concurrent interview, CNA 3 acknowledged not performing hand hygiene and stated that infection prevention and hand hygiene are important because they prevent residents from harm. In the same room, CNA 4 was observed entering from the hallway and approaching to feed the same resident without performing hand hygiene. In a concurrent interview, CNA 4 acknowledged not practicing hand hygiene and stated that hand hygiene is very important to keep residents safe because they are weak and can easily get sick. Record review showed the resident had diagnoses including anoxic brain damage, UTI, a disorder involving the immune mechanism, and heart failure, and was cognitively impaired and dependent on staff for substantial/maximal assistance with eating and personal hygiene. The ADON stated that all staff are trained and expected to perform hand hygiene before and after resident care, and the IP stated that hand hygiene is a standard precaution and agreed that staff were supposed to perform hand hygiene before feeding a resident. The facility’s Infection Prevention and Control Program policy indicated that infection prevention includes educating staff and ensuring adherence to proper techniques and following CDC guidelines.
Failure to Develop Discharge Care Plans for Three Cognitively Intact Residents
Penalty
Summary
The facility failed to develop discharge care plans for three sampled residents, despite facility policy that discharge planning begins at admission and should be updated after discharge meetings and every three months. Interview and record review showed that Residents 1, 2, and 3, all with intact cognition, did not have discharge care plans in their medical records. The medical record assistant confirmed that no discharge care plans were found for these residents, and the director of social services stated that discharge planning is expected to start at admission. Resident 1, an older female admitted with a left humerus fracture, generalized muscle weakness, encephalopathy, cystitis, bilateral knee osteoarthritis, anxiety, hypertension, major depressive disorder, and repeated falls, was documented as dependent for toileting, bathing, and transfers. Resident 2, an older female with osteoarthritis of the knee, morbid obesity, dysphagia, schizoaffective disorder, bipolar disorder, and glaucoma, was also dependent for toileting, bathing, and transfers. Resident 3, an older female with spinal stenosis, fibromyalgia, knee osteoarthritis, diabetes mellitus, morbid obesity, anxiety, insomnia, GERD, and major depressive disorder, required maximal assistance with toileting, bathing, and transfers. Despite these documented care needs and intact cognition, no discharge care plans were developed for any of the three residents.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving two residents to the Department of Public Health and the Ombudsman within the required two-hour timeframe, as outlined in the facility's own Abuse Investigation and Reporting policy. The incident occurred when one resident alleged that another resident hit him on the leg, and law enforcement was called to the facility. The facility became aware of the abuse allegation at approximately 5:30 AM, but the report to the state survey agency was not made until 9:09 AM, exceeding the mandated two-hour reporting window. Interviews with staff confirmed awareness of the reporting requirement and acknowledged the delay in notification. The resident who made the allegation had a history of heart failure, diabetes mellitus, and cystitis, and was dependent on staff for personal care, with intact cognitive ability. The other resident involved had diagnoses including a left thigh fracture, heart failure, and diabetes mellitus. The facility's policy required immediate reporting of abuse allegations, especially those involving abuse or resulting in serious bodily injury, but this protocol was not followed in this instance, as evidenced by the delayed fax confirmation of the report.
Failure to Provide Social Services After Abuse Allegations
Penalty
Summary
The facility failed to provide medically-related social services to four out of six sampled residents by not ensuring the Social Services Director (SSD) assessed the residents' psychosocial well-being after incidents involving physical and/or verbal abuse allegations. Specifically, after one resident alleged being hit by another and law enforcement was called, there was no documented follow-up or assessment by the SSD for either resident involved. In another incident, two residents exchanged verbal abuse in the activity room, witnessed by staff, but again, there was no documented psychosocial assessment or intervention by the SSD for those involved. Additionally, a resident reported being hit on the wrist by a roommate and stated that the SSD did not come to speak with him about his feelings, despite expressing a desire for such support. Interviews with the SSD confirmed that follow-up was not conducted with several residents involved in these incidents, and in one case, although the SSD claimed to have followed up with a resident, there was no documentation of these interactions. The facility's own policies and job descriptions require the SSD to address and document the psychosocial needs of residents, particularly following abuse allegations. The lack of timely and documented follow-up by the SSD after abuse allegations meant that the psychosocial needs of the affected residents were not assessed or addressed as required. This failure was acknowledged by both the SSD and the facility's nurse consultant, who stated that such follow-up is necessary to identify and meet residents' psychosocial needs. The omission was contrary to facility policy and the expectations outlined in the social worker's job description.
Failure to Timely Respond to Resident Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents by not ensuring their call lights were answered in a timely manner, as required by facility policy. Resident 4, who had systemic lupus erythematosus, pain from orthopedic devices, generalized muscle weakness, and partial traumatic amputation of both feet, was dependent on staff for mobility and toileting. Resident 4 reported that it often took twenty to thirty minutes for staff to respond to call lights, resulting in prolonged periods of being wet and soiled, which exacerbated pain and discomfort. Resident 4 stated that despite raising concerns with staff, the issue persisted. Resident 5, diagnosed with cardiomyopathy, hypertension, and anxiety disorder, was also dependent on staff for transfers and mobility. Resident 5 reported frequent delays in call light response, particularly at night, and expressed feelings of neglect after complaints to the night shift charge nurse did not resolve the issue. Interviews with CNAs confirmed that residents commonly complained about delayed call light responses, especially during shift changes or when staffing was reduced due to call-outs. The DON acknowledged that facility policy required immediate or prompt response to call lights, and that call lights were the primary means for residents to request assistance.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The facility failed to adequately supervise and monitor the whereabouts of a resident who was admitted with significant psychiatric diagnoses, including bipolar disorder with psychotic features, schizoaffective disorder, and a recent history of hearing voices instructing self-harm. Upon admission, the resident was identified as being at risk for elopement, and behavioral monitoring was indicated as a primary focus. Despite these risk factors, the resident was able to leave the facility without notifying staff, and their whereabouts remained unknown following the incident. Record reviews revealed inconsistencies and incomplete documentation regarding the resident's expressed desire to leave against medical advice (AMA). Although the resident signed an AMA form, it was missing a date and staff witness signatures, and the physician order summary did not indicate a discharge. Staff interviews indicated that the resident had previously expressed a wish to leave, but was convinced to stay, leading to the incomplete processing of the AMA form. On the day of the incident, staff discovered the resident missing during routine rounds, and subsequent searches and notifications were made to authorities and facility leadership. Observations during the survey found that staff were not consistently monitoring resident whereabouts, particularly during shift changes. No staff were observed making rounds or present at key monitoring locations such as nurses' stations, and certain facility areas, such as a service elevator, were not visible from staff workstations. Staff interviews confirmed that resident accountability was not ensured during shift changes, increasing the risk of elopement for residents identified as high risk.
Failure to Report and Address Nonfunctioning Thermostats and Temperature Regulation
Penalty
Summary
Facility maintenance failed to report nonfunctioning thermostats to administration for three sampled residents, resulting in the air conditioning unit being turned off at night due to an inability to regulate building temperatures. This led to resident complaints about excessive heat during nighttime hours. Observations and interviews confirmed that maintenance staff routinely turned the HVAC system on and off from the roof, as there were no functioning thermostats to regulate temperature, and staff were unaware of the last time the HVAC system was serviced. Maintenance staff also did not inform administration about the nonfunctioning thermostats or the ongoing temperature regulation issues. Residents affected by this deficiency included individuals with significant medical conditions such as peripheral neuropathy, migraines, obesity, cardiovascular disease, stroke with hemiplegia, major depressive disorder, anxiety, hypotension, COPD, spinal stenosis, fibromyalgia, osteoarthritis, diabetes mellitus, morbid obesity, cellulitis, insomnia, GERD, hypertension, and nicotine dependence. Some residents required maximal assistance with activities of daily living and had impaired cognition, while others were dependent on staff for toileting and bathing. Multiple residents reported discomfort due to heat at night, and observations confirmed that fans in resident rooms were not always functional or circulating air. Despite the presence of 55 portable air conditioning units in storage, maintenance staff did not offer these units to residents who complained about the heat, nor did they notify administration of the temperature control issues. Facility policy required that all temperature complaints and malfunctions be reported to administration and documented, but this process was not followed. The maintenance supervisor and assistant were aware of the portable units but did not distribute them or escalate the issue, resulting in continued resident discomfort and noncompliance with facility policy regarding temperature regulation.
Residents Subjected to Forced Removal from Power Wheelchairs and Loss of Mobility Rights
Penalty
Summary
The facility failed to protect two residents from mental and physical abuse when unidentified corporate staff forcefully removed them from their motorized power wheelchairs (MPWC) and placed them into manual wheelchairs (MWC) against their wishes and without clinical justification or consent. The incident involved multiple staff members, including corporate representatives, who attempted to physically transfer the residents despite their verbal refusals and distress. The residents were not provided with an opportunity to speak with law enforcement when the police were called, and their autonomy and right to make decisions regarding their mobility devices were disregarded. One resident, with a history of multiple medical conditions including cellulitis, pressure injuries, chronic pain, and dependence on a wheelchair, was subjected to forceful attempts to remove her from her MPWC. She repeatedly expressed her desire to keep her MPWC and asked to speak with familiar staff or her physician, but was ignored. During the incident, several staff members physically attempted to remove her from the chair, causing her emotional distress and pain in her left arm and shoulder. She was left in a manual wheelchair and confined to bed for an extended period, resulting in psychosocial harm such as anxiety, helplessness, and emotional distress. She was later transferred to a hospital for evaluation of shoulder pain. Another resident, diagnosed with multiple sclerosis, Parkinson's disease, and other conditions leading to dependence on a wheelchair, was also removed from her MPWC by a group of unfamiliar staff. She was transferred to bed using a Hoyer lift and left without her preferred mobility device for several days, which led to her remaining in bed, crying, and experiencing a loss of independence. Both residents' care plans indicated their dependence on MPWCs for mobility and participation in activities, yet these were disregarded by the staff involved. The actions taken by the facility staff resulted in both residents experiencing a loss of autonomy, dignity, and independence, as well as significant psychosocial harm.
Failure to Maintain Audible Phone Ringing at Nursing Stations
Penalty
Summary
The facility failed to maintain the nursing station phone ringers at an audible volume across all four nursing stations, as observed during multiple call attempts. When calls were transferred from the main facility phone line to each nursing station, the phones did not ring audibly at the stations, and staff only became aware of incoming calls after hearing overhead pages instructing them to answer the phone. Interviews with LVNs at each station confirmed that the phone volumes were turned down all the way, preventing them from hearing the phones ring. Staff acknowledged the importance of having the phone volume set at an audible level to ensure calls from doctors, family members, and patients could be answered promptly. A review of the facility's policy and procedures regarding telephone usage indicated that employees should exercise thoughtfulness and courtesy in using telephones and that staff should not be paged to the phone unless it is an emergency. Despite this policy, the phones at all nursing stations were not set to ring audibly, resulting in reliance on overhead paging to alert staff to incoming calls. This practice had the potential to limit or delay communication with medical professionals, family members, and staff.
Failure to Ensure Timely IV Fluid Administration
Penalty
Summary
The facility failed to provide appropriate intravenous (IV) access care according to its own policies and procedures for one resident. The resident, who had multiple diagnoses including hypertension, diabetes mellitus type 2, muscle weakness, gait abnormalities, heart failure, and asthma, was admitted with an order for Dextrose 5% IV solution to be infused at 50 ml per hour over 20 hours for hydration. On observation, the IV bag was found hanging with approximately 550 ml remaining, not infusing, and the bag was dated two days prior. The IV was connected to the resident's right forearm, but no drops were observed in the drip chamber, indicating the infusion was not running as ordered. A family member reported that the IV had not been infusing for at least 40 minutes and mentioned previous issues with the IV tubing. The Registered Nurse Supervisor was unaware of the IV order and had to check the resident's chart to confirm the order. Upon further interview, the nurse acknowledged forgetting about the IV order despite being informed by the prior shift. The facility's policy requires licensed nurses to be knowledgeable about the length of time needed to administer IV medications, to assess the IV site and system, and to review provider orders for correct administration, all of which were not followed in this instance.
Failure to Explain and Obtain Signature for Admission Agreement at Admission
Penalty
Summary
The facility failed to explain and obtain a signature for the admission agreement at the time of admission for one resident, as required by its policy and procedures. The resident, an elderly female with multiple complex medical conditions including ventricular fibrillation, morbid obesity, diabetes, asthma, congestive heart failure, vascular dementia, and a pressure ulcer, was admitted without the proper completion of the admission agreement. The Minimum Data Set assessment indicated that the resident did not have intact cognition and was dependent on staff for toileting, personal hygiene, and transfers. Documentation and interviews revealed that the resident's family member did not receive the admission packet until several weeks after admission, despite being present at the facility daily. The family member sent questions regarding the admission agreement via email, but did not receive timely responses from the admissions coordinators. The facility's policy requires that the admission agreement, which outlines covered and non-covered services and payment responsibilities, be explained and signed at admission, but this process was not followed, resulting in a lack of clarity regarding the services provided and covered by the facility versus the resident's insurance.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report and Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to follow its policy regarding the timely reporting and investigation of a resident-to-resident altercation involving two residents. One resident, who had intact cognitive skills and required moderate assistance with activities of daily living, reported that another resident, who had moderately impaired cognition and a high risk of wandering, entered his room, sat on his bed, and opened his drawer. The first resident became upset and threw water at the second resident in the hallway. Progress notes documented the incident, and staff indicated they would continue to monitor the second resident's behavior. Despite the documentation of the incident, the facility did not investigate or report the event to the appropriate authorities, including the State, Local Ombudsman, or Police, as required by facility policy and federal regulations. Both the RN and DON acknowledged during interviews that the incident should have been reported and investigated, but no such actions were taken. The facility's policy mandates the identification, investigation, and timely reporting of all possible incidents of abuse, neglect, or misappropriation of resident property, which was not followed in this case.
Failure to Ensure Proper Use of BiPAP Machine for Resident with Sleep Apnea
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident with a diagnosis of obstructive sleep apnea, type II diabetes mellitus, and asthma. The resident was admitted with a physician's order for a BiPAP machine to be used nightly from 9 p.m. until the resident woke up, or as needed, with supplemental oxygen as ordered. Record review showed that the resident was severely cognitively impaired and required total staff assistance for activities of daily living. The care plan included the use of the BiPAP machine during sleep to maintain normal breathing and prevent complications related to shortness of breath. However, the BiPAP compliance report indicated the resident's average usage was only 2 hours and 16 minutes per night, significantly less than the prescribed duration. Interviews with nursing staff and the DON revealed that the BiPAP machine was frequently leaking and alarming at night, indicating it was not properly set or functioning while on the resident. The night shift nurses were reportedly informed to ensure the BiPAP was properly set, but the issue persisted. The DON stated that nurses should be competent in operating and troubleshooting the BiPAP machine, and the physician confirmed that the resident was not receiving the intended therapy duration. Facility policy required documentation of therapy duration, resident tolerance, and physician notification if the resident refused or experienced adverse consequences, but the report did not indicate these steps were consistently followed.
Failure to Ensure Competency and Timely Response by Nursing Staff
Penalty
Summary
Nurses and nurse aides at the facility failed to demonstrate appropriate competencies in caring for residents, resulting in several deficiencies. One resident, a female with multiple complex diagnoses including metabolic encephalopathy, COPD, diabetes, morbid obesity, paraplegia, and other chronic conditions, was observed to have her call light out of reach and left on for an extended period without response. The resident reported being left in an uncomfortable position for about 30 minutes, experiencing significant back pain, and expressed dissatisfaction with a registry CNA who was unfamiliar with her care needs and did not follow her preferences. The call light panel in her room was also found to be hanging out of the wall with exposed wires, though still functional. Staff members, including CNAs, were observed not wearing ID badges, and some were unfamiliar with the residents or the facility's procedures due to infrequent assignments and lack of orientation or huddles at the start of their shifts. Another resident, also with multiple chronic conditions such as spinal stenosis, COPD, morbid obesity, and congestive heart failure, reported a negative experience with a registry CNA who took an extended break, delayed meal service, and failed to complete required showers. The resident felt unsafe during care and noted communication barriers with some registry CNAs who did not speak or understand English well enough to meet her needs. The staffer confirmed that the registry CNA was not familiar with the resident's preferences and was subsequently marked as 'do not return' based on the resident's complaints. Record reviews revealed that competency checklists for registry CNAs were incomplete or missing, with most only documenting competency in resident transfers and lacking evidence of skills in other required areas. The facility had no Director of Staff Development (DSD) to oversee training, and the infection prevention nurse, who had been covering some training duties, had not provided competency training for registry staff. The facility's policy required all nursing staff to demonstrate competency in a range of skills, but there was no evidence that this was consistently ensured for registry CNAs.
Failure to Provide Timely Physical Therapy Evaluations
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically physical therapy (PT) evaluations, for six out of seven sampled residents who had physician orders for PT evaluation and treatment. Despite documented medical needs such as hemiplegia, hemiparesis, recent amputations, vertebral fractures, and other mobility-impairing conditions, these residents did not receive timely PT assessments upon admission. The absence of a licensed PT on staff led to delays, with the facility relying on agency PTs who were only available on an as-needed basis, rather than consistently present to perform required evaluations. Multiple interviews with staff, including the acting director of rehabilitation (a certified occupational therapy assistant), confirmed that PT evaluations were difficult to obtain due to the lack of an in-house PT. The COTA stated they could not perform PT evaluations and that agency PTs were only intermittently available. Residents and family members reported concerns, including one resident who did not receive assistance with prosthetic legs and another whose back brace was not properly applied for several days due to lack of PT involvement. These issues were corroborated by the Ombudsman and family interviews, which highlighted the residents' unmet rehabilitative needs and dissatisfaction with the care provided. Record reviews showed that all six residents had physician orders for PT evaluation and treatment, but these were not fulfilled in a timely manner. Facility policy required that specialized rehabilitative services be provided by qualified personnel upon physician order, but the lack of a consistent PT presence resulted in noncompliance with this policy. The deficiency placed residents at risk of a decline in mobility and failure to address their rehabilitative needs as ordered by their physicians.
Failure to Provide Consistent Dining Room Access for Dinner
Penalty
Summary
The facility failed to honor residents' rights to self-determination and choice by not consistently opening the dining room for dinner to all residents every day. Interviews with staff, including the activity director (AD) and restorative nursing assistant (RNA), revealed that while the dining room was regularly open for lunch, it was not always available for dinner. The AD stated that since their employment, residents typically ate breakfast and dinner in their rooms, and the dining room was only used for lunch. The RNA confirmed that the dining room operated from 9:00 a.m. to 4:00 p.m., with no clear information about dinner service. The director of nursing (DON) initially believed the dining room was open for all meals but later learned from the AD that staffing shortages prevented consistent dinner service in the dining room. A review of a specific resident's records showed that the resident, who had intact cognition and was independent with eating and mobility using a manual wheelchair, normally ate dinner in his room due to the lack of staff to facilitate dinner in the dining room. The resident indicated that this issue had been previously discussed with facility administration but was never resolved. Facility policies reviewed stated that all residents should be encouraged to eat in the dining room and that staff should assist those who require help with meals, emphasizing dignity and respect. The facility's own policies on resident rights and meal assistance highlighted the importance of supporting resident choice and providing a dignified dining experience. However, the practice of not opening the dining room for dinner to all residents every day was found to be inconsistent with these policies and constituted a violation of residents' rights to self-determination and choice regarding their dining preferences.
Insufficient Staffing Limits Dining Room Access for Meals
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure the dining room was open and available to residents for all meals, as required. Observations and interviews revealed that residents were only able to eat in the dining room for lunch, while breakfast and dinner were typically served in residents' rooms. The activity director confirmed that since their employment, the dining room had only been used for lunch, and was unaware of the reason for this practice. The restorative nursing assistant also stated that the dining room opened at 9:00 a.m. and closed at 4:00 p.m., with breakfast being served in residents' rooms and uncertainty about dinner service due to their shift ending before dinner time. Staffing records and interviews indicated significant staffing challenges, including multiple certified nursing assistants calling off and being replaced by registry staff or other personnel. The director of nursing initially stated that residents could eat in the dining room for any meal, but later acknowledged, after speaking with the activity director, that the dining room was not always open for dinner due to insufficient staff to monitor residents during meals. This lack of staffing directly impacted residents' ability to exercise their right to dine in the dining room at all mealtimes. A resident with a history of hemiplegia, hemiparesis, stroke, and other medical conditions reported that he normally ate dinner in his room because there was not enough staff to facilitate dinner in the dining room. This issue had been previously discussed with the former administrator but remained unresolved. The facility's own policy stated that staffing levels should be based on resident needs and care plans, and that support services should be adequately staffed to meet those needs, which was not met in this instance.
Failure to Timely Report and Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its policy regarding the timely reporting and investigation of an alleged staff-to-resident abuse incident. A resident with severe cognitive impairment and significant physical disabilities was the subject of an allegation that a CNA was rough during ADL care and pushed the resident from the bed. The allegation was initially reported by the resident's roommate, who stated she informed the nursing staff, but observed that the CNA continued to work on the same floor throughout the week. Interviews with staff confirmed that the CNA was separated from the residents involved but was not suspended and continued working in the facility. Documentation review revealed that the incident was not reported to all required agencies, including the district office, Ombudsman, physician, family, and police, as mandated by facility policy. The SBAR documentation completed by the RN did not fully reflect the details of the allegation as reported by the resident, and the investigation findings were not submitted within the required five-day period. The DON confirmed that all abuse allegations should be reported and investigated according to policy, but there was no evidence that this was done in this case. The facility's written policy requires immediate reporting of abuse allegations within two hours if abuse or serious bodily injury is involved, and a written report of the investigation findings within five working days. In this instance, the facility did not adhere to these requirements, resulting in a delay in the Department of Public Health's onsite inspection and potentially delaying the prevention of further abuse for the resident involved.
Failure to Provide Physical Therapy Services Due to Lack of PT Staff
Penalty
Summary
The facility failed to employ a full-time Physical Therapist (PT) to provide specialized rehabilitative services to its 144-bed capacity, resulting in the absence of PT services for residents who may require evaluation and treatment. At the time of the survey, there were no PT staff working in the facility, as the previous PT had resigned approximately two weeks prior. Interviews with the Occupational Therapist and the Director of Nursing confirmed that there were about nine residents with current physician orders for physical therapy who were not receiving these services. Review of the facility's policy indicated that specialized rehabilitative services, including physical therapy, are to be provided by qualified professional personnel as indicated by resident assessments.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required for facilities with more than 120 beds. The Social Services Director (SSD), who met the qualifications, had not been present in the facility since February due to a family emergency. In the absence of the SSD, the Social Service Assistant (SSA), who does not possess the required educational background or supervised social work experience, assumed the roles and responsibilities of the SSD. Review of the SSA's employee file confirmed the lack of necessary qualifications. During this period, a resident with multiple diagnoses, including osteoarthritis, asthma, and spinal stenosis, and who required significant assistance with activities of daily living, reported not having met with the SSD since readmission. The resident had only interacted with the SSA regarding non-clinical concerns and had not participated in a care plan meeting. The facility's policy requires a qualified social worker to provide medically-related social services to support residents' well-being, but this standard was not met due to the absence of a qualified SSD.
Failure to Promptly Respond to Resident Call Light
Penalty
Summary
A deficiency occurred when staff failed to promptly respond to a resident's call light. The resident, who had diagnoses including type II diabetes mellitus, fibromyalgia, and chronic kidney disease, required maximal to total assistance with activities of daily living and was assessed as cognitively intact. The resident's care plan included an intervention to ensure the call light was within reach and to encourage its use for assistance. During an observation, the call light was seen blinking outside the resident's room and the alarm was audible at the nursing station. The resident reported having pressed the call light over 30 minutes prior and was waiting for help to put on underpants, remaining in only an incontinent brief during this time. Staff interviews revealed that the LVN responded to the call light after the extended wait and then sought out a CNA to assist the resident, as the CNA was occupied with another resident. Both the LVN and the DON confirmed that call lights should be answered immediately by any available staff, and the facility's policy required call lights to be answered immediately, with requests fulfilled within five minutes if possible. The failure to respond promptly to the call light resulted in the resident not receiving timely assistance for personal care needs.
Single-Staff Mechanical Lift Transfer Performed Against Policy
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident from a shower chair to bed using a mechanical Hoyer lift without the required assistance of a second staff member. The resident involved had diagnoses including congestive heart failure, depressive disorder, and age-related osteoporosis, and was assessed as totally dependent on staff for activities of daily living. The resident's care plan specified the use of a Hoyer lift for transfers due to limited physical mobility, and the facility's policy required at least two nursing assistants for safe operation of the mechanical lift. During observation, the CNA was seen performing the transfer alone, and later confirmed in an interview that he believed it was permissible to use the Hoyer lift with only one person. However, both a licensed vocational nurse (LVN) and the director of nursing (DON) stated that two staff members are required for such transfers to ensure resident safety. Review of facility policy further confirmed this requirement. The failure to follow established procedures placed the resident at risk during the transfer.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the Department of Public Health and the Ombudsman within the required two-hour timeframe, as outlined in the facility's Abuse Investigation and Reporting policy. The incident involved a resident with a history of metabolic encephalopathy, COPD, and heart failure, who was assessed as having moderate cognitive impairment and required assistance with activities of daily living. The alleged verbal abuse occurred during an overnight shift when a CNA was reported to have called the resident 'crazy' after the resident became upset about being woken for incontinence care. Documentation showed that the incident was noted in the resident's progress notes and care plan, and staff statements confirmed that the allegation was communicated to supervisory staff. However, the report to the Department of Public Health was not made until several hours after the incident, well beyond the two-hour requirement. The delay was attributed to a busy shift and a misunderstanding about which shift was responsible for making the notification. Interviews with staff, including the CNA, LVN, RN supervisor, and the administrator, confirmed the timeline of events and the failure to report the allegation promptly. The facility's policy clearly required immediate reporting of abuse allegations, but this protocol was not followed, resulting in a delay in notifying the appropriate authorities about the alleged verbal abuse.
Failure to Prevent and Intervene in Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to develop and implement interventions to prevent ongoing verbal abuse between two residents sharing a room. One resident, who was dependent on staff for toileting, showering, and transfers due to multiple medical conditions including bilateral osteoarthritis, anemia, and hypertension, reported repeated incidents of verbal abuse and controlling behavior by her roommate. These incidents included the roommate pushing her bed, blocking the door with a wheelchair or walker, making derogatory remarks, and dictating the use of lights and television in the room. The affected resident expressed fear and distress, stating that she had reported these issues to staff but saw no changes. Staff interviews and record reviews confirmed that the roommate frequently blocked the door, used offensive language, and created a hostile environment. A certified nursing assistant (CNA) witnessed the roommate obstructing access to the room and making derogatory comments, and reported these incidents to the director of staff development (DSD). However, there was no evidence that effective interventions were put in place to address or stop the abusive behavior. The social service assistant (SSA) and registered nurse (RN) both documented ongoing conflicts between the residents, with both refusing room changes, but no further follow-up or resolution was documented after grievances were filed. Despite multiple reports and observations of the abusive interactions, facility leadership, including the DSD, regional director, and administrator, were either unaware of the extent of the verbal abuse or did not take further action beyond offering room changes. The facility's own policy required prompt investigation and intervention in cases of alleged abuse, but the lack of follow-up and failure to implement protective measures left the resident at continued risk for verbal abuse.
Failure to Develop Care Plan for Resident with Liver Transplant
Penalty
Summary
The facility failed to develop a care plan addressing a resident's history of liver transplant. Review of the resident's admission record showed multiple complex diagnoses, including paranoid schizophrenia, anemia, diabetes mellitus, major depressive disorder, kidney transplant, and liver transplant. The resident was noted to be cognitively intact but required varying levels of assistance with activities of daily living. Despite these complexities, there was no care plan specific to the liver transplant documented in the resident's records. During an interview and record review with the DON, it was confirmed that a care plan for the liver transplant was missing, and the DON acknowledged that such a plan should have been in place to guide staff in providing appropriate care. The facility's policy and procedures require a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident, but this was not followed for the resident with a liver transplant.
Failure to Communicate Elopement Risk and Ensure Resident Identification
Penalty
Summary
The facility failed to ensure that services met professional standards of quality by not properly communicating a resident's high risk for elopement and by not ensuring the resident wore an identification (ID) wristband. A resident with significant cognitive impairment, including diagnoses of parkinsonism, major depressive disorder, dysphagia, and neurocognitive disorder with Lewy bodies, was admitted with orders for frequent monitoring and the use of a Wanderguard device due to elopement risk. Despite these orders, staff assigned to the resident were not formally notified of the elopement risk, and the resident was not included on the CNA assignment sheet. The CNA caring for the resident was unaware of the resident's risk status or the purpose of the Wanderguard, as this information was not communicated during shift handoff or morning huddle. Additionally, the resident was observed on multiple occasions without an ID wristband, contrary to facility policy requiring such identification for resident safety and proper administration of care. Staff interviews confirmed that the resident should have had an ID wristband and that the lack of communication regarding the resident's risk status and identification requirements contributed to the deficient practice. Facility policies reviewed indicated the necessity of both the Wanderguard system for elopement risk and the ID wristband for resident identification, but these were not consistently implemented for the resident in question.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to follow physician's orders for wound care treatment for a resident with a skin tear on the right wrist/hand. The resident, who was admitted with diagnoses including parkinsonism, major depressive disorder, dysphagia, and neurocognitive disorder with Lewy bodies, was documented as lacking the mental capacity to make medical decisions and was dependent on staff for daily activities. The care plan indicated that skin tears should be treated per facility protocol, and an active physician's order specified cleansing the wound with normal saline, patting dry, applying xeroform, and covering with a dry dressing. During observation, the resident's skin tear was found to be scabbed and open to air without a dressing. The LVN present was unaware if the wound should be covered, stating that a treatment nurse typically performed wound care. The DON later stated that the wound did not need to be covered since it was scabbed, but acknowledged that if there was an order, it should be followed. The facility's wound care policy required following physician's orders and care plans for wound treatment.
Failure to Communicate Elopement Risk and Ensure Resident Identification
Penalty
Summary
The facility failed to ensure proper communication and implementation of safety measures for a resident identified as high risk for elopement. The resident, who had diagnoses including parkinsonism, major depressive disorder, dysphagia, and neurocognitive disorder with Lewy bodies, was assessed as lacking the mental capacity to make medical decisions and was severely cognitively impaired. Documentation indicated the resident had a history of leaving the facility and was at risk for elopement, with orders in place for frequent monitoring and the use of a Wanderguard device. However, staff assigned to the resident were not formally notified of the resident's elopement risk, and the resident was not included on the CNA assignment sheet. The CNA caring for the resident was unaware of the purpose of the Wanderguard or the resident's risk status due to lack of communication during shift handoff and morning huddles. Additionally, the resident was observed without an identification wristband on multiple occasions, contrary to facility policy requiring such identification for resident safety. Staff interviews confirmed that the absence of the ID wristband could hinder proper identification and safe care delivery. The facility's policies on Wanderguard use and resident identification were not followed, as evidenced by the lack of communication regarding the resident's risk status and the missing ID wristband, placing the resident at increased risk for elopement and other safety incidents.
Failure to Prevent Repeated Falls and Injuries in High-Risk Resident
Penalty
Summary
The facility failed to ensure a resident at risk for falls was adequately supervised and monitored, resulting in repeated falls and injuries. Despite being identified as a fall risk due to a history of falls, dementia, muscle wasting, and unsteady gait, the resident experienced three separate falls over a six-month period. The care plan, titled 'Falling Star Program,' included interventions such as keeping the bed in the lowest position, locking wheelchair wheels, maintaining a clutter-free environment, and using non-skid footwear. However, these interventions were not consistently implemented or revised after each fall, and the effectiveness of the care plan was not evaluated following subsequent incidents. After each fall, documentation showed that the interdisciplinary team (IDT) and staff did not adequately address or update interventions to prevent future falls. For example, after the resident was found on the floor with injuries, the care plan was not revised to include more intensive supervision or additional safety measures. The facility also failed to ensure the resident's environment was free from hazards, as evidenced by an incident where the resident slipped on a puddle of urine by the bedside, leading to a severe hip fracture that required surgical intervention. Observations further revealed that the resident's call light was not within reach, and the resident was seen attempting to get out of bed unsupervised, stepping on a wet floor mat. Interviews with staff confirmed lapses in supervision and environmental safety. The DON acknowledged that the resident should have been placed on one-to-one care with a sitter, as outlined in the care plan, but this was not done. Additionally, staff failed to follow the facility's own policies and procedures regarding fall risk management, which required re-evaluation and modification of interventions after each fall. These failures directly contributed to the resident's repeated falls and resulting injuries.
Failure to Notify Physician and Document Change of Condition
Penalty
Summary
Facility staff failed to notify the physician when a resident experienced a change of condition, specifically after the resident complained of a sore throat, swallowing issues, and body itching. The resident, who had diagnoses including congestive heart failure, diabetes mellitus, and dementia with severely impaired cognitive skills, was admitted to the facility and later tested positive for Pertussis. Despite the resident's complaints and the family member's request for lab testing, there was no documented evidence that staff recognized or reported these symptoms as a change of condition or incident of concern. Interviews with facility staff, including a registered nurse and the infection preventionist nurse, confirmed that the required documentation and physician notification were not completed when the resident exhibited these symptoms. The facility's policy required prompt notification of the physician and documentation of any changes in a resident's condition, but this protocol was not followed in this instance. The lack of documentation and notification was validated by both the nursing and infection prevention staff during the survey.
Failure to Document and Address Resident Grievances per Facility Policy
Penalty
Summary
The facility failed to document and address grievances according to its policy for one resident. The resident, who was admitted with diagnoses including congestive heart failure, diabetes mellitus, and dementia, had severely impaired cognitive skills and required moderate assistance with activities of daily living. The resident's family member expressed dissatisfaction with the lack of activities provided and the inability to reach department heads or receive timely responses from nursing staff. These concerns were documented in the resident's progress notes by the Social Service Director. Despite these documented concerns, a review of the facility's grievance records for the relevant period showed no completed grievance forms for the resident. During an interview, the Director of Nursing confirmed that there was no documentation of grievances for this resident and acknowledged that the Social Service Director should have assisted the family member in submitting a grievance form, as required by facility policy. The facility's policy states that upon receiving a grievance, an investigation should begin and a grievance report form should be filed within five working days, which was not done in this case.
Failure to Inventory and Return Residents' Personal Belongings
Penalty
Summary
The facility failed to protect the personal belongings of two residents by not properly inventorying and documenting their possessions upon admission and discharge. For one resident with diagnoses including congestive heart failure, diabetes mellitus, and dementia, there was no inventory of personal belongings recorded in the medical record at either admission or discharge. The DON confirmed that staff are required to complete and document an inventory of personal belongings at these times, but this was not done for the resident, who had severely impaired cognitive skills and required moderate assistance with activities of daily living. For another resident with metabolic encephalopathy, malnutrition, and atrial fibrillation, the inventory of personal belongings was incomplete and lacked discharge signatures from the resident or their representative. The record showed that additional items were delivered by family during the stay, but there was no documentation that the belongings were returned to the resident or their representative upon transfer to a general acute care hospital. The DON acknowledged that the facility did not follow its policy to ensure belongings were returned and properly documented, as required by facility procedures.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. Upon review, it was found that the resident was admitted with multiple diagnoses, including congestive heart failure, diabetes mellitus, and dementia, and required moderate assistance with activities of daily living due to severely impaired cognitive skills. Despite these needs, the initial care plans addressing falls, allergies, pain/discomfort, and skin integrity were not initiated until ten days after admission. The Director of Nursing confirmed that the baseline care plans were not completed within the required 48-hour timeframe, as stipulated by the facility's policy and procedures. The delay in initiating these care plans was verified through interviews and record reviews, which showed that the resident's immediate health and safety needs were not formally addressed in a timely manner following admission.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of four residents by not ensuring that televisions were operational and hot water was consistently available. Residents 4, 5, and 6 reported that their televisions were non-functional for three days, which affected their ability to watch programs and stay updated with current news. Additionally, Residents 4, 5, 6, and 7 experienced issues with hot water availability during showers, with Resident 4 stating that hot water was often unavailable since admission, and Resident 5 having to shower early to avoid running out of hot water. Resident 6 expressed reluctance to shower due to consistently cold water, and Resident 7 reported an inability to shower consistently due to frequent hot water shortages. Interviews with the Maintenance Director and Nursing Consultant revealed that the Maintenance Director was newly hired and still assessing building issues, while the Nursing Consultant acknowledged the facility's responsibility to accommodate residents' needs and preferences. The facility's policy on accommodation of needs emphasized assisting residents in maintaining safe, independent functioning and dignity, and stated that individual needs and preferences should be accommodated to the extent possible. However, the facility's failure to ensure working televisions and consistent hot water supply demonstrated a lack of adherence to this policy, potentially impacting the residents' psychosocial well-being and delaying necessary care.
Resident's Right to Privacy Breached by Receiving Opened Mail
Penalty
Summary
The facility failed to protect a resident's right to privacy by not ensuring that the resident received unopened mail. During an interview and record review, it was found that a resident, who was admitted with conditions including spinal stenosis, obesity, and COPD, received an opened letter addressed to them. The resident expressed feeling uneasy about this breach of privacy, as it is their right to receive unopened mail. The facility's Nursing Consultant confirmed that residents' mail should not be opened, aligning with the facility's California Standard Admission Agreement for Skilled Nursing Facilities, which states that patients have the right to receive unopened personal mail. Additionally, the facility's policy and procedure on Resident Rights and Release of Information emphasize treating residents with respect and maintaining the confidentiality of their personal and protected health information.
Delayed Response to Call Light Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of its residents, specifically affecting one resident who experienced a significant delay in response to a call light. Resident 4, who was admitted with a fracture of the right femur and low back pain, had intact cognition and required no assistance for activities of daily living. However, when Resident 4 activated the call light to request ice chips, the response was delayed by over one and a half hours. The facility's policy mandates that call lights should be answered immediately to ensure timely responses to residents' needs. During an interview, the facility's Nursing Consultant confirmed that call lights should be answered without delay. This deficiency in staffing and response time has the potential to affect the quality of life and delay necessary care for residents, as evidenced by the experience of Resident 4.
Failure to Appoint Licensed Administrator
Penalty
Summary
The facility failed to ensure that a licensed administrator was appointed by the Governing Board, which had the potential to affect resident care and management of the facility. During a review of the posted licensing information on the facility's consumer bulletin board, it was observed that no administrator license was posted. In an interview, the Acting Administrator (AA) stated that his license was not displayed because he was not appointed by the governing board, as he would exceed the 200-bed limit for supervision. The facility's policy and procedure documents indicated that the administrator should be appointed by and accountable to the governing board, and a licensed administrator is responsible for the day-to-day functions of the facility.
Failure to Appoint Licensed Administrator
Penalty
Summary
The facility failed to ensure that a licensed administrator was appointed by the governing board, which is a requirement for managing and operating the facility. During an observation of the facility's consumer bulletin board, it was noted that there was no administrator license posted. In an interview, the Acting Administrator (AA) stated that his license was not posted because he had not been appointed by the governing board, as he would exceed the 200-bed limit for supervision. The facility's policy and procedure documents, reviewed in November 2024, indicated that the administrator should be appointed by and accountable to the governing board and is responsible for the day-to-day functions of the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observations and interviews. Staff were observed placing personal items, such as a Monster energy drink, in the kitchen refrigerator, which could potentially contaminate food meant for residents. This was confirmed by the Dietary Supervisor, who acknowledged the risk of contamination and illness to residents. Additionally, staff did not adhere to hand hygiene protocols. A Certified Nurse Assistant (CNA) was seen handling dirty linen without gloves and failed to perform hand hygiene afterward. Another CNA exited a droplet precaution room without wearing the required N95 mask and gloves, and also did not perform hand hygiene after doffing an isolation gown inappropriately. The Infection Prevention Nurse confirmed that there was no infection control training documented for one of the CNAs, highlighting a gap in staff training and competency. The facility also did not ensure that medical equipment was handled properly. A resident's nasal cannula tubing was found on the floor, and another resident's nebulizer equipment was not covered, posing a risk of contamination. The Director of Nursing acknowledged that these practices could lead to respiratory infections. Furthermore, during an influenza outbreak, staff were observed wearing N95 masks improperly, which could contribute to the spread of infection among residents. The facility's policies on infection control and personal protective equipment were not consistently followed, as evidenced by these observations.
Failure to Maintain Accurate Advance Directives
Penalty
Summary
The facility failed to ensure that the clinical records of four residents were complete and updated concerning advance directives. This deficiency was identified during interviews and record reviews, where it was found that the facility did not maintain an accurate and current copy of the residents' advance directives in their clinical records. The absence of these documents had the potential to cause conflict with the residents' wishes regarding healthcare, particularly in situations where they were unable to communicate their preferences. Resident 72 was admitted with diagnoses including hypertension, anxiety disorder, and muscle weakness, and was found to have severely impaired cognition. Resident 27, with Type 2 Diabetes Mellitus and hypertension, had moderately impaired cognition but was independent in activities of daily living. Resident 65, diagnosed with anxiety disorder and depression, had severely impaired cognition and required assistance with daily activities. Resident 114, with dementia and Alzheimer's disease, also had severely impaired cognition and required supervision for daily activities. None of these residents had their advance directives documented in their records. Interviews with facility staff, including the Social Services Director and a Licensed Vocational Nurse, revealed that the process for obtaining and documenting advance directives was not consistently followed. The Social Services Director stated that residents or their representatives are asked about advance directives during admission, and if they do not have one, they are offered the opportunity to complete one. However, if they refuse, a form indicating their refusal should be maintained in the chart, which was not done in these cases. The Director of Nursing emphasized the importance of having advance directives in the chart to honor residents' last wishes, but this protocol was not adhered to, leading to the identified deficiency.
Latest citations in California
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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