Sherman Oaks Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Sherman Oaks, California.
- Location
- 14401 Huston St., Sherman Oaks, California 91423
- CMS Provider Number
- 056250
- Inspections on file
- 46
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Sherman Oaks Health & Rehab during CMS and state inspections, most recent first.
A resident with osteoporosis, dementia, and hypertension, and with moderately impaired cognition, had a care plan and MD order for a low air loss mattress (LALM) to prevent pressure ulcers. Surveyors observed the LALM made with a fitted sheet, two cloth chux, and a disposable brief, contrary to facility practice and staff statements that only one sheet and one chux or brief should be used. An LVN and the DON explained that extra linen layers interfere with air circulation and can create pressure and friction, and a CNA acknowledged placing two chux under the resident. This was inconsistent with the facility’s support surface guidelines for PU prevention.
A resident with diabetes and other comorbidities, who was oriented and knowledgeable about her medications, reported that an LVN brought an insulin pen labeled with another resident’s name to her bedside and placed it on her tray table. The resident noticed the incorrect name on the pen, informed the LVN, and photographed the pen, after which the LVN removed it and returned with insulin pens labeled for the correct resident and administered the insulin. The LVN later stated she had placed an expired insulin pen for another resident and the correct resident’s insulin pen on top of the medication cart and mistakenly picked up the wrong pen when bringing medications into the room, contrary to facility policy and standard practice requiring verification of the five rights and preparation of medications for only one resident at a time.
A resident with DM2, morbid obesity, and HTN had orders for basal and sliding-scale insulin. One evening, an LVN preparing medications placed multiple residents’ insulin pens on top of the med cart and inadvertently brought an insulin pen labeled for another resident into the room, placing it on the bedside tray. The alert resident recognized the wrong name on the pen, informed the LVN, and the LVN then retrieved and used the correct insulin pen. The LVN later acknowledged she had mistakenly grabbed the other resident’s pen and also acknowledged that she did not document this medication error in the medical record, despite facility policies and nursing staff statements that all medication errors and related incidents must be charted. Review of the record confirmed there was no nursing note about the incident, resulting in an incomplete clinical record for the resident.
A resident with intact cognitive skills reported that a visitor used inappropriate language towards her, which staff recognized as verbal abuse. Although the incident was reported to staff, a miscommunication prevented the administrator from being fully informed, resulting in a failure to notify the State Survey Agency, ombudsman, and law enforcement within the required two-hour timeframe. This delay led to a late investigation and potentially placed the resident at risk.
A resident's EHR containing sensitive medical information was left open and unattended at a nurses' station, with no staff present to monitor the workstation. The DON confirmed that staff are required to lock EHRs when not in use, and facility policy mandates that computer terminals be shielded and logged off when unattended. This failure resulted in a breach of privacy and confidentiality for the resident's protected health information.
A resident with hemiplegia and high fall risk, dependent on staff for transfers and requiring a mechanical lift with two-person assistance, was transferred by staff without the required lift. Following the transfer, the resident developed new leg pain, swelling, and bruising, and was later diagnosed at a hospital with a left knee fracture. Staff interviews confirmed the transfer was performed improperly and not in accordance with facility policy.
Two medication carts were found open and unattended in a nurses' station, as confirmed by the DON during an interview. Facility policy requires medication carts to be locked when out of staff view, but this was not followed, creating the potential for unauthorized access to medications.
CNAs failed to accurately and timely document the percentage of food consumed by three residents with severe cognitive impairments and complex medical conditions. Meal intake records were often incomplete, missing, or recorded at incorrect times, leading to inaccurate medical records. Facility leadership confirmed that documentation did not meet professional standards or facility policy.
A resident with moderate risk for pressure ulcers and impaired mobility was found to have a low air-loss mattress set incorrectly at 160 lbs, despite weighing 115 lbs. Staff interviews and record reviews confirmed the mattress should have been set to 120 lbs according to the resident's weight and manufacturer guidelines. This failure to follow professional standards and facility policy placed the resident at risk for pressure ulcer development.
The facility failed to obtain proper informed consent for psychotropic medications for several residents, including those with major depressive disorder and dementia. Incomplete consent forms lacked signatures from residents or their representatives and prescribing physicians, leading to the administration of medications without documented consent. This oversight was acknowledged by the facility's RN and DON, highlighting a failure to follow policy and potentially resulting in the use of unnecessary psychotropic drugs.
The facility did not make the most recent survey results accessible to residents and their representatives, as required by policy. Residents were unaware of where to find the survey results, and the binder was not visible or up-to-date. The Administrator confirmed the importance of making these results available, but the facility failed to comply with its own policy.
The facility failed to follow proper protocols for the use of restraints on two residents. A resident had a bed alarm applied without a restraint assessment, physician's order, informed consent, or care plan, while another resident had pillows tucked under the fitted sheet as a restraint without the necessary documentation and approvals. These actions did not comply with the facility's policy on restraint use, which requires thorough assessment and documentation.
Two residents in an LTC facility did not receive proper monitoring for medication side effects and effectiveness. One resident, on blood thinners for atrial fibrillation, was not monitored for bleeding, while another, on atorvastatin for hyperlipidemia, did not have lipid levels checked. The facility's policies required such monitoring, but it was not documented.
The facility's nursing staff failed to rotate insulin injection sites for three residents, leading to a deficiency in care. Despite physician's orders and guidelines, insulin was repeatedly administered in the same areas, risking adverse effects. The DON and RN acknowledged the oversight and the importance of site rotation to prevent skin complications.
The facility failed to maintain a safe environment for residents, leading to multiple deficiencies. A resident at high risk for falls had floor mats obstructed by equipment, compromising their effectiveness. Another resident's room had environmental hazards like protruding nails, and a third resident was left unattended in a high bed position during wound care, increasing fall risk. These actions violated facility policies aimed at ensuring resident safety.
The facility failed to properly administer and document oxygen therapy for residents requiring respiratory care. A resident with metabolic encephalopathy and dementia received oxygen therapy without consistent documentation on the MAR. Another resident with Alzheimer's Disease also received oxygen therapy without proper documentation and monitoring. Additionally, a resident's oxygen tubing was observed touching the floor, posing a risk of infection. These deficiencies could lead to respiratory distress and infections.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, as required by their care plan and facility policy. The resident, dependent on hemodialysis, had multiple instances where post-HD assessments were not documented, potentially delaying care and detection of complications. Interviews confirmed the importance of these assessments, yet documentation was incomplete despite regular staff training.
A facility failed to account for three doses of controlled medications for three residents, leading to a deficiency in pharmaceutical services. An LVN admitted to administering the medications but did not document the administration on the accountability logs, violating facility policy. This lack of documentation increased the risk of medication errors and potential harm to the residents, who required these medications for chronic pain, pressure ulcers, and neuropathy.
A CP failed to report irregularities in drug regimen reviews for two residents, leading to deficiencies in monitoring for adverse effects of medications. One resident on blood thinners was not monitored for bleeding, and another on atorvastatin was not monitored for lipid levels. The DON acknowledged the lack of documentation, and the CP admitted to missing these issues in reviews.
A facility failed to monitor drug regimens and side effects for three residents, leading to potential unnecessary drug use. One resident on Eliquis, clopidogrel, and gabapentin lacked monitoring for bleeding and drug toxicity. Another resident on atorvastatin had no lipid panel conducted since admission. A third resident on apixaban lacked monitoring for adverse effects. The facility's policies emphasized the need for such monitoring to prevent harm.
The facility failed to ensure appropriate use of psychotropic medications for several residents, including administering lorazepam without proper documentation, prescribing mirtazapine and divalproex without specific target behaviors, and administering sertraline and divalproex sodium without informed consent. Additionally, alprazolam was prescribed PRN without a stop date, leading to potential unnecessary medication use.
A facility failed to maintain a medication error rate below five percent, resulting in a 12.5% error rate. Two residents experienced errors: one received carvedilol at the wrong time, an incorrect multivitamin, and missed polyethylene glycol; another received carvedilol late. LVNs cited being busy as the cause. The facility's policy requires medications to be administered within a 60-minute window, which was not followed.
The facility failed to rotate insulin injection sites for three residents, leading to significant medication errors. Despite physician's orders and guidelines, insulin was repeatedly administered in the same areas, risking adverse effects. This deficiency was confirmed through record reviews and staff interviews.
The facility failed to update its staffing plan, resulting in medication administration delays for two residents. LVNs were assigned more residents than the assessed ratio of 1 LVN to 24 residents, leading to late administration of carvedilol. The facility's assessment had not been updated since 12/1/2024, despite changes in resident acuity.
The facility failed to maintain an effective infection prevention and control program by using permeable linen cart covers, which allowed contamination from dust and liquids. Observations and interviews revealed that all 17 linen carts were covered with unsuitable materials, and the cleaning methods used were not aligned with the manufacturer's guidelines or facility policies. This deficiency had the potential to spread infections among residents and staff.
A resident with a DNR order was mistakenly given CPR after being found unresponsive due to a failure in filing the correct documentation in their current chart. The oversight led to the assumption that the resident was full code status, resulting in a violation of their rights to dignity and respect.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating resident needs. One resident with dementia and a history of falls had the call light hanging on the wall, while another alert and oriented resident had the call light on the floor. Staff acknowledged the oversight and confirmed the importance of having call lights accessible to ensure timely responses to residents' needs.
The facility failed to assist two residents with formulating Advance Directives (ADs) upon admission, despite their severe cognitive impairments and need for assistance with daily activities. The facility's records lacked documentation of any inquiry or assistance offered to the residents' representatives regarding ADs, contrary to the facility's policy. Interviews confirmed that necessary steps were not taken, potentially impacting the residents' care in emergencies.
The facility failed to maintain a safe and homelike environment for two residents. One resident had a damaged floor mat that was not replaced, despite being at high risk for falls. Another resident's room had a broken baseboard and windowsill with exposed nails and debris, and unrelated red letters on the wall, creating an unsafe and institutional setting. These conditions were not in line with the facility's policy for a homelike environment.
A facility failed to provide a written notice of the bed-hold policy to a resident's representative during a hospital transfer. The resident, with diagnoses including metabolic encephalopathy and sepsis, was transferred due to medical issues, but the required notification was not given, as confirmed by staff interviews. This oversight could lead to the resident being moved to a non-preferred facility.
A resident with a documented DNR order was administered CPR after being found unresponsive, due to a failure in filing the resident's PIC Authorization/Decisions form in the current chart. The oversight led staff to consider the resident as full code status, resulting in a violation of the resident's rights and preferred treatment wishes.
A resident with significant medical conditions was transferred to a hospital due to elevated WBC and BUN levels, but the facility failed to perform a required change of condition assessment. This omission was confirmed by staff interviews and contradicted the facility's policy, potentially impacting the resident's care.
Two residents with urinary catheters were at risk of UTIs due to improper catheter care. One resident with obstructive uropathy had a suprapubic catheter with a loop in the tubing, preventing proper drainage. Another resident with benign prostatic hyperplasia had a foley catheter with coiled tubing, also hindering drainage. Staff confirmed the need for proper catheter alignment to prevent backflow and infection, as per facility policy.
A resident with chronic conditions and significant weight loss was not provided Ensure, a nutritional supplement, as ordered by the physician. The resident reported a weight drop from 195 to 144 pounds, and the LVN confirmed the oversight. The facility's policies required adherence to physician orders and documentation of nutritional support, which was not followed in this case.
The facility failed to properly administer IV fluids for two residents. One resident had a loose and soiled PICC line dressing that was not changed promptly, and another resident's PIV injection port lacked a sterile cap. These deficiencies were observed during a random inspection and confirmed by staff interviews and policy reviews, placing residents at risk for infection.
A facility failed to conduct a quarterly assessment for bed rail entrapment risk for a resident with dementia and a history of falls. Despite the resident's high fall risk and impaired cognition, the last assessment was over a year ago. The facility's policy required quarterly assessments to ensure safe use of bed rails, which were not followed, as confirmed by staff interviews.
A facility failed to label intravenous meropenem with a resident's name, as required for safe medication administration. The medication was taken from an emergency kit due to a pharmacy delay, and the oversight was acknowledged by the RN. The DON confirmed that the facility's policy, which mandates labeling to prevent errors, was not followed.
A facility failed to follow up with an endocrinologist after a resident's HbA1c test result indicated poor blood sugar control. Despite notifying the attending physician, there was no documentation of follow-up with the endocrinologist to adjust the resident's diabetes management. This oversight placed the resident at risk for complications related to uncontrolled blood sugar levels.
The facility failed to label a pitcher of cranberry juice with the date it was poured, as observed during a kitchen tour with the DM. The DM and DON acknowledged that the staff should have dated the pitcher to ensure freshness and prevent potential food-borne illnesses. The facility's policy requires all refrigerated foods to be labeled and dated, which was not adhered to in this instance.
A facility failed to accurately document a resident's elopement risk, despite the resident's condition indicating a risk. The resident, with cerebral infarction and dementia, required substantial assistance with daily activities. Elopement risk assessments inaccurately documented the resident as not at risk, despite a calculated score indicating otherwise. MDS Nurses acknowledged the documentation error, which contradicted the facility's policy requiring objective, complete, and accurate records.
A facility failed to ensure a fair arbitration process for a resident with cognitive impairments by using an outdated arbitration agreement that did not provide for a neutral arbitrator or a convenient venue. Despite having updated the agreement in 2019, the facility used a version from 2007, potentially disadvantaging the resident during arbitration. The Admission's Coordinator and Administrator acknowledged the oversight, noting the importance of the agreement in waiving the right to a jury trial.
A facility failed to ensure proper hospice care for a resident by not obtaining the hospice doctor's signature on the initial Certification of Terminal Illness and not receiving the updated hospice plan of care from the hospice provider. This lack of documentation and communication could negatively impact the resident's care.
A facility failed to complete a resident's MDS Quarterly Assessment within the required timeframe. The assessment, due by 1/10/2025, was completed late on 1/13/2025, as confirmed by the Final Validation Report. This delay could affect timely reporting of the resident's health status and quality measures, as noted by the MDS Nurse and DON.
The facility failed to ensure accurate MDS assessments for two residents, affecting their care plans. One resident's admission date was incorrectly coded, impacting billing and health status documentation. Another resident's discharge status was not accurately reflected, potentially causing confusion and delays in care. The facility's policy requires certification of MDS accuracy, which was not followed.
Improper Use of Low Air Loss Mattress for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure appropriate use of a low air loss mattress (LALM) for a resident identified as being at risk for pressure ulcer (PU) development. The resident was admitted with diagnoses including age-related osteoporosis, unspecified dementia, and essential hypertension, and had moderately impaired cognitive skills for daily decision making per the MDS. The resident’s care plan for pressure ulcers, last revised on 1/6/2026, identified a potential for PU development and included the use of pressure-relieving devices as needed. A physician’s order dated 3/17/2026 specified a LALM for skin care management. During an observation on 4/1/2026, the resident’s LALM was found with one fitted sheet, two layers of cloth chux, and a disposable brief between the resident and the mattress. An LVN stated that facility practice for LALM use required only one flat sheet and one chux or disposable brief, and explained that more than two layers of linen would prevent air circulation, create pressure, and trap moisture. A CNA reported that she had changed the resident’s disposable brief and placed two chux between the resident and the LALM before going on lunch break. The DON confirmed that LALM use in the facility required only one linen and one chux or disposable brief and acknowledged that multiple linen layers could prevent air circulation and cause friction. The facility’s Support Surface Guidelines policy indicated that redistributing support surfaces are used to prevent skin breakdown, promote circulation, and provide pressure relief or reduction, and to monitor for other PU risk factors and provide interventions as indicated.
Insulin Pen Labeled for Another Resident Brought to Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an LVN brought an insulin pen labeled for a different resident to the bedside. The affected resident had type 2 diabetes mellitus, morbid obesity, and essential hypertension, and required varying levels of assistance with activities of daily living. The resident had physician orders for Insulin Glargine 60 units at bedtime, to be held if blood sugar was less than 100, and Insulin Lispro per sliding scale before meals and at bedtime. On the evening in question, the resident reported that an LVN entered the room around 11 p.m. with an insulin pen that had a male resident’s name on the label and placed it on the bedside tray table. The resident, who was oriented and knowledgeable about her medications, read the name on the pen, recognized it did not belong to her, and informed the LVN. The resident took a photo of the insulin pen, which showed a male first and last name corresponding to another resident. The resident stated that after pointing out the error, the LVN left the room with the incorrect pen and later returned with an insulin pen labeled with the correct name, after which the insulin injection was administered. The resident reported feeling stressed after discovering the medication error. In a subsequent interview, the LVN explained that while preparing medications at the cart outside the resident’s room, she removed an expired insulin pen that did not belong to the resident and placed it on top of the cart to address later. She then removed the correct resident’s insulin pen from the container and also placed it on the same side of the cart. While gathering the rest of the resident’s medications, she inadvertently picked up the other resident’s insulin pen from the top of the cart and brought it into the room, stating she had not yet read the name on the pen when the resident noticed the error. The DON and another LVN described the standard process for medication administration, including verifying the “five rights” and preparing medications for only one resident at a time, and facility policies required checking the medication label three times to ensure the right resident, medication, dose, time, and route. The incident occurred when these procedures were not followed, resulting in the wrong resident’s insulin pen being brought to the bedside and observed by the resident.
Failure to Document Insulin Medication Error Resulting in Incomplete Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure a complete and accurate medical record for one resident when a medication error was not documented in accordance with facility policy. The resident had a history of type 2 diabetes mellitus, morbid obesity, and essential hypertension, and required varying levels of assistance with activities of daily living. The resident had physician orders for Insulin Glargine 60 units at bedtime, to be held if blood sugar was less than 100, and Insulin Lispro per sliding scale before meals and at bedtime. On the evening in question, the resident reported that an LVN entered the room around 11:00 p.m. with an insulin pen labeled with another resident’s name and placed it on the bedside tray table. The resident recognized that the insulin pen did not belong to her, informed the LVN, and took a photo of the pen showing a male resident’s first and last name. The LVN then left the room with the incorrect insulin pen and returned with the correct insulin pen labeled with the resident’s name, after which the resident received her insulin injection. The resident stated she felt stressed after discovering the medication error. In a subsequent interview, the LVN acknowledged that she had separated an expired insulin pen belonging to another resident from the medication cart container and placed it on top of the cart, then also placed the resident’s insulin pen on the same side of the cart while preparing medications. The LVN stated she mistakenly grabbed the other resident’s insulin pen from the top of the cart and brought it into the resident’s room, and that the resident identified the wrong name on the pen before administration. The LVN admitted she did not document this medication error and only reported it verbally to her RN supervisor. Review of the resident’s electronic medical record showed no nursing progress notes documenting a medication error or incident on that date. The DON and nursing staff stated that standard practice and facility policies require documentation of medication errors or incidents in the resident’s clinical record, including a factual description of the error and events, incidents, or accidents involving the resident. The failure to document the medication error resulted in an incomplete medical record for the resident on that date. Interviews with other nursing staff confirmed that insulin pens are labeled by pharmacy with resident names, that nurses are expected to verify the “five rights” (right patient, drug, dose, route, and time) when preparing and administering medications, and that medication errors must be documented in the clinical record. The facility’s policies on Charting and Documentation and on Adverse Consequences and Medication Errors require that events, incidents, or accidents involving the resident, and any medication errors, be documented in the resident’s medical record, including a factual description of the error. Despite these requirements, no documentation of the incident involving the wrong insulin pen was found in the resident’s record.
Failure to Timely Report Allegation of Verbal Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of visitor-to-resident verbal abuse within the required two-hour timeframe to the State Survey Agency, the ombudsman, and local law enforcement, as outlined in its own policies. A resident, who was cognitively intact and able to make decisions, reported that a visitor used inappropriate language towards her due to a complaint about a loud television. The incident was reported by the resident to a Social Service Assistant (SSA) the following morning, who then notified the Administrator (ADM) and attempted to address the issue with the visitor. Multiple staff interviews confirmed that the allegation of verbal abuse was recognized and discussed among staff, including the SSA, a Licensed Vocational Nurse (LVN), and a Registered Nurse (RN). Each staff member acknowledged that the use of inappropriate language constituted verbal abuse and that such allegations should be reported immediately to the appropriate authorities. However, there was a breakdown in communication between the SSA and the ADM, resulting in the ADM not being fully informed of the abuse allegation and, therefore, not initiating the required reporting and investigation procedures. The facility's policies clearly state that all allegations of abuse must be reported to the administrator and relevant authorities within two hours if abuse is involved. Despite this, the miscommunication led to a delay in reporting the incident, and the required notifications and investigation were not initiated in a timely manner. This failure resulted in a delay in the investigation and had the potential to place the resident at risk for abuse.
EHR Left Unattended, Compromising Resident Privacy
Penalty
Summary
Staff failed to maintain the privacy and confidentiality of a resident's medical records when an electronic health record (EHR) was left open and unattended at a nurses' station. During an observation with the Director of Nursing (DON), it was noted that the EHR containing the resident's personal and medical information was accessible, with no staff present to monitor the workstation. The DON confirmed that staff are required to lock EHRs when not in use to prevent unauthorized access, as leaving them open poses a risk of exposing protected health information. The resident involved had been admitted with diagnoses including hypertension, type 2 diabetes mellitus, and a history of falls. Assessment records indicated the resident was dependent on staff for several activities of daily living and was able to understand and communicate. Facility policy required that computer terminals be shielded from public view and that users log off or clear screens when leaving workstations unattended, which was not followed in this instance.
Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all surface-to-surface transfers and required the use of a mechanical lift with two-person assistance, was transferred without the use of the required mechanical lift. The resident had significant medical conditions, including hemiplegia affecting the right side, cerebral infarction, and end stage renal disease, and was assessed as a high fall risk. Facility records, including the Minimum Data Set and a facility-provided record, indicated that the resident's transfer protocol required a Hoyer lift and two-person assistance. On the day of the incident, the resident complained of new left leg pain and swelling, which was assessed by nursing staff. The resident reported to staff that a male staff member had transferred her without the Hoyer lift, and this was confirmed by interviews with the CNA and LVN involved. The resident's leg was found to be swollen, warm, and later developed significant bruising. Medical evaluation and imaging at a general acute care hospital revealed a left knee fracture involving the anterior tibial tuberosity and patellar tendon, with severe swelling and moderate effusion. Interviews with facility staff, including the CNA, LVN, RN, and Administrator, confirmed that the resident was transferred improperly, without the required mechanical lift and two-person assistance, which was not in accordance with the facility's policies and procedures. The improper transfer was identified as the cause of the resident's fracture, and the event resulted in the resident's transfer to the hospital for further evaluation and treatment.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that two medication carts, identified as Medication Cart 1 and Medication Cart 2, were left open and unattended in Nurses' Station 2. This observation was made during a concurrent interview with the Director of Nursing (DON), who confirmed that both carts were open and acknowledged that all medication carts should be locked when staff are out of sight. The DON stated that locking the carts is necessary for resident safety, as unlocked carts could allow unauthorized access to medications. A review of the facility's Policy and Procedures (P&P) titled 'Security of Medication Carts,' last reviewed on 9/27/2024, indicated that medication carts must be securely locked at all times when out of the nurse's view. The failure to lock the medication carts when unattended was identified as a deficient practice, as it had the potential to allow residents or unauthorized personnel access to the medications stored within the carts.
Failure to Accurately Document Resident Meal Intake in Medical Records
Penalty
Summary
The facility failed to ensure that medical records for three residents were maintained in accordance with accepted professional standards and practice. Certified Nursing Assistants (CNAs) did not consistently document the percentage of food consumed by the residents at the correct times, resulting in incomplete and inaccurate nutritional intake records. For example, there were multiple instances where meal intakes were either not documented at all or were recorded at times that did not correspond with actual meal times, such as breakfast and lunch intakes being documented in the afternoon or evening. Resident 1, who had diagnoses including pneumonia, osteoarthritis, and dementia with severely impaired cognitive skills, had several days where meal intakes were missing or documented inaccurately. CNA 1 confirmed that the documentation was incomplete and not reflective of when meals were actually consumed. The Director of Staff Development also acknowledged that the documentation was incomplete and inaccurate, which could affect the identification of causes for weight changes. Similar issues were found for two other residents, both with significant cognitive impairments and medical conditions such as chronic kidney disease, hemiplegia, encephalopathy, and osteoarthritis. Their records also showed missing or inaccurately timed meal intake documentation. The Director of Nursing confirmed that CNAs should document meal intake after consumption and that records should not be left blank. The facility's own policy required that all services and changes in condition be documented objectively, completely, and accurately, but this standard was not met in these cases.
Failure to Set Low Air-Loss Mattress Correctly for Pressure Ulcer Prevention
Penalty
Summary
A resident with diagnoses including pneumonia, osteoarthritis, and dementia was admitted to the facility and assessed as being at moderate risk for pressure ulcer development, as indicated by a Braden Scale score of 14. The resident had severely impaired cognitive skills and required maximal assistance for mobility. Physician orders specified the use of a low air-loss mattress (LALM) for skin management. However, observations and interviews revealed that the LALM was set to 160 lbs, while the resident's actual weight was 115 lbs, as confirmed by both a CNA and LVN. The LALM setting was not adjusted according to the resident's weight, contrary to the manufacturer's guidelines and facility policy. Staff interviews confirmed that the LALM should have been set to 120 lbs based on the resident's weight, and that charge and treatment nurses were responsible for ensuring correct settings. The DON acknowledged that the incorrect LALM setting rendered the device ineffective in preventing pressure ulcers. Review of facility policy and the LALM operation manual further supported that mattress settings should be based on the resident's weight. This failure to ensure the LALM was set appropriately placed the resident at risk for the development of pressure ulcers.
Deficiency in Informed Consent for Psychotropic Medications
Penalty
Summary
The report identifies a deficiency in the facility's process of obtaining informed consent for the use of psychotropic medications for several residents. Resident 48 was admitted with diagnoses including major depressive disorder and congestive heart failure. Despite having the capacity to understand and make decisions, the informed consent forms for trazodone hydrochloride and temazepam were incomplete, lacking signatures from both the resident or their representative and the prescribing physician. This oversight was acknowledged by the RN and DON, who confirmed that the consent process was not followed, potentially leaving the resident unaware of the risks and benefits of the medications. Similarly, Resident 8, who was diagnosed with unspecified mood disorder and dementia, did not have completed informed consent forms for divalproex sodium and sertraline. The resident's capacity to understand and make decisions was impaired, necessitating consent from a representative. However, the forms were blank, and the medications were administered without documented consent. The MDS Nurse and DON both recognized the failure to obtain informed consent, which could result in the administration of psychotropic medications without the family's knowledge or agreement. The report also highlights deficiencies in the informed consent process for Residents 96 and 89. Resident 96, with diagnoses of anxiety disorder and major depressive disorder, had incomplete informed consent forms for sertraline and alprazolam, lacking documentation of who consented to the medication use. Resident 89, diagnosed with major depressive disorder and dementia, did not have a new informed consent obtained when the dosage of quetiapine was increased. The DON confirmed that the facility's policy was not followed, denying residents their rights to informed care and potentially leading to the use of unnecessary psychotropic drugs.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to promote resident rights by not making the most recent survey results easily accessible to residents, family members, and legal representatives. During an interview with seven resident council group attendees, it was revealed that they were unaware of where to find the survey results. They pointed to a black metal rack outside the Activity Director's office, but upon inspection, no survey binder was found there. The Activity Director later indicated that the binder was placed on a table outside the social services and admissions office, but it was not visible as it was placed underneath the tabletop without a sign. Additionally, the binder did not contain the most recent recertification survey results from 2024. The Administrator acknowledged that the State inspection results should be available for all residents and their representatives to understand what the facility is working on. The facility's policy and procedure on Resident Rights, last reviewed in September 2024, stated that a copy of the most recent standard survey should be maintained in a three-ring binder in an area frequented by most residents, such as the main lobby or resident activity room. However, the facility did not adhere to this policy, resulting in residents and their representatives not having access to examine the most recent survey results.
Failure to Follow Restraint Protocols for Residents
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, as evidenced by the cases of two residents. Resident 49 had a bed alarm applied without a restraint assessment, physician's order, informed consent, or a care plan. The bed alarm was used because Resident 49 was at high risk for falls, but the necessary procedures to justify its use as a restraint were not followed. This oversight placed Resident 49 at risk for restriction of movement, which could lead to a decline in physical function. Resident 267 was found with pillows tucked under the fitted sheet on both sides of the bed, which restricted the resident's movement. This was done as a safety measure due to the resident's history of falls and attempts to dangle legs over the bed. However, there was no restraint assessment, physician's order, informed consent, or care plan in place for this intervention. The use of pillows in this manner was acknowledged by staff as a form of restraint, yet the proper protocols were not followed, potentially leading to a decline in the resident's functioning. The facility's policy on the use of restraints requires a thorough assessment, physician's order, informed consent, and a care plan before implementing any restraint. These steps were not taken for either resident, indicating a failure to adhere to the facility's own policies and procedures. The Director of Nursing confirmed that the use of pillows as a restraint was not acceptable and that the necessary steps were not taken to ensure the safety and well-being of the residents involved.
Failure to Monitor Medication Side Effects and Effectiveness
Penalty
Summary
The facility failed to implement the care plans for two residents, leading to deficiencies in monitoring for adverse effects of medications. Resident 42, who was prescribed Eliquis and clopidogrel for atrial fibrillation, did not receive monitoring for signs and symptoms of bleeding and bruising, as outlined in their care plan. Additionally, Resident 42 was prescribed gabapentin for epilepsy, but there was no documentation of monitoring for drug toxicity, which was also required by the care plan. Resident 79, diagnosed with hyperlipidemia and prescribed atorvastatin, did not have a lipid panel conducted to monitor the effectiveness of the medication. The care plan for Resident 79 required monitoring of lipid levels to assess the risk of cardiac distress and the effectiveness of atorvastatin, but no such monitoring was documented. The Director of Nursing acknowledged the lack of documentation and monitoring for both residents, which was considered a standard of practice. The Consultant Pharmacist also failed to identify these deficiencies in their monthly drug regimen reviews. The facility's policies and procedures emphasized the importance of monitoring for adverse drug reactions and maintaining the highest level of resident functionality, which were not adhered to in these cases.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards by not rotating subcutaneous insulin administration sites for three residents, leading to a deficiency in care. Resident 17, who was readmitted with diagnoses including type 2 diabetes mellitus and dementia, had physician's orders for insulin administration that required site rotation. However, the Medication Administration Record (MAR) indicated that the insulin was repeatedly administered in the same area, contrary to the physician's orders and the manufacturer's guidelines. This oversight was acknowledged by RN 1 and the Director of Nursing (DON), who both confirmed the necessity of site rotation to prevent adverse effects such as pain and skin complications. Similarly, Resident 48, who had intact cognition and required assistance with activities of daily living, also received insulin injections without proper site rotation. The MAR showed repeated administration in the same abdominal areas, despite clear physician's orders to rotate sites. RN 1 and the DON reiterated the importance of following the guidelines to prevent skin issues and other complications associated with improper insulin administration. Resident 107, admitted with type 2 diabetes mellitus and other health conditions, also experienced the same deficiency. The Location of Administration Report revealed multiple instances where insulin was administered in the same site, contrary to the facility's policy and the manufacturer's guidelines. The DON confirmed that the licensed nurses should have rotated the injection sites to prevent potential adverse effects. This consistent failure to rotate injection sites for insulin administration across multiple residents highlights a significant lapse in adhering to professional standards of care.
Failure to Maintain a Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to multiple deficiencies. Resident 4, who was at high risk for falls due to dementia and other conditions, had floor mats intended to prevent injury from falls. However, observations revealed that a wheelchair and an overbed table were placed on top of these mats, compromising their effectiveness. Staff interviews confirmed that placing items on the mats was against policy and could lead to injury if the resident fell. Similarly, Resident 272, also at high risk for falls, had floor mats improperly placed with equipment on top of them, and a bed alarm was not installed as ordered. Observations and staff interviews highlighted that these practices could affect the integrity of the mats and increase the risk of injury during falls. The facility's policies emphasized the importance of keeping the environment free from obstacles and ensuring interventions were properly implemented, which was not adhered to in these cases. Additionally, Resident 70's room had environmental hazards, including a broken baseboard with protruding nails and a damaged windowsill, which were not addressed promptly. The Maintenance Director admitted to leaving the hazards unattended for a week, and the DON acknowledged the potential for injury. Furthermore, Resident 13 was left unattended in a high bed position during wound care, contrary to safety protocols, increasing the risk of falls. These deficiencies demonstrate a failure to maintain a safe environment and adhere to established safety policies.
Deficiencies in Oxygen Therapy Administration and Documentation
Penalty
Summary
The facility failed to ensure proper administration and documentation of oxygen therapy for residents requiring respiratory care. Resident 70, who was readmitted with diagnoses including metabolic encephalopathy, sepsis, and dementia, was observed receiving oxygen therapy via nasal cannula. However, there was a lack of documentation on the Medication Administration Record (MAR) for the administration of PRN oxygen, despite the resident's oxygen saturation levels being recorded. Interviews with nursing staff revealed inconsistencies in the documentation process, with some staff acknowledging the importance of documenting oxygen administration but failing to do so consistently. Similarly, Resident 74, diagnosed with Alzheimer's Disease and other conditions, was observed receiving oxygen therapy without proper documentation in the MAR. The resident had a physician's order for PRN oxygen, but the administration was not consistently recorded, and there was no evidence of monitoring for the effectiveness of the oxygen therapy. Staff interviews indicated a lack of adherence to the facility's policy on documenting PRN oxygen use, which could lead to unnecessary administration and failure to address underlying causes of respiratory distress. Additionally, the facility failed to maintain proper infection control practices for Resident 96, whose oxygen tubing was observed touching the floor. This practice poses a risk of respiratory infections due to potential contamination. The facility's policy requires immediate replacement of contaminated tubing, but this was not adhered to, as confirmed by staff interviews. These deficiencies in respiratory care and infection control practices have the potential to place residents at risk for respiratory distress and infections.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis (HD) received treatment consistent with professional standards of practice. The deficiency involved a lack of documented assessments by licensed nurses after the resident's HD sessions. This failure was identified for one resident who was dependent on HD due to end-stage renal disease and hypertension. The resident was admitted to the facility with these diagnoses and had a care plan in place to document the condition post-HD. The facility's policy required licensed nurses to perform and document post-HD assessments immediately upon the resident's return from the dialysis center. These assessments were crucial to detect any changes in the resident's condition, such as changes in consciousness, bleeding from the arteriovenous shunt, or changes in vital signs. However, the review of the resident's Dialysis Communication Record forms revealed multiple instances where these assessments were not documented, indicating they may not have been performed. Interviews with the Minimum Data Set Nurse and the Director of Nursing confirmed the importance of these assessments and the facility's policy requirements. Despite monthly in-services on completing the Dialysis Communication Record, the documentation was incomplete, suggesting non-compliance with the facility's policy. The lack of documentation for post-HD assessments placed the resident at risk for delayed care and detection of potential complications from HD.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to account for three doses of controlled medications for three residents, leading to a deficiency in pharmaceutical services. During an observation and interview, it was found that there was a discrepancy between the controlled drug record accountability log and the actual medication count in the medication cart. Specifically, one dose of Belbuca for Resident 5, one dose of hydrocodone with acetaminophen for Resident 97, and one dose of pregabalin for Resident 272 were missing from the medication cart or bubble pack compared to the accountability log. Licensed Vocational Nurse (LVN) 3 admitted to administering the medications to the residents but failed to document the administration on the accountability logs as per the facility's policy and procedures. This failure to document immediately after administration led to a lack of control and accountability for the controlled medications, increasing the risk of medication errors and potential harm to the residents. The Director of Nursing confirmed that LVN 3 did not follow the facility's policy of documenting the preparation and administration of controlled medications immediately. The residents involved had specific medical conditions requiring these medications. Resident 5 was prescribed Belbuca for chronic pain, Resident 97 was prescribed hydrocodone with acetaminophen for pain management related to pressure ulcers and disc degeneration, and Resident 272 was prescribed pregabalin for neuropathy. The failure to document the administration of these medications accurately could lead to medication errors and potential harm to the residents, as noted by LVN 3 and the Director of Nursing.
Failure to Monitor Medication Side Effects and Effectiveness
Penalty
Summary
The Consultant Pharmacist (CP) failed to report irregularities in the monthly drug regimen review for two residents, leading to deficiencies in monitoring for potential adverse effects of medications. Resident 42, who was prescribed Eliquis and clopidogrel for atrial fibrillation, was not monitored for signs and symptoms of bleeding and bruising, which are critical due to the blood-thinning nature of these medications. Additionally, Resident 42 was prescribed gabapentin for epilepsy but was not monitored for signs of drug toxicity, such as nausea, dizziness, or chest pain, as outlined in the resident's care plan. Resident 79, diagnosed with hyperlipidemia and prescribed atorvastatin, was not monitored for lipid levels through a lipid panel, which is essential to assess the effectiveness of the medication and adjust the treatment plan if necessary. The facility's policies and procedures require such monitoring to prevent adverse consequences and ensure the medications are providing the intended benefits without causing harm. The Director of Nursing (DON) acknowledged the lack of documentation and monitoring for both residents, which was supposed to be recorded in the Medication Administration Record (MAR). The CP admitted to failing to identify these monitoring deficiencies in the drug regimen reviews conducted over several months. The facility's policies emphasize the importance of monitoring for adverse drug reactions and maintaining the highest practicable level of functioning for residents, which was not adhered to in these cases.
Failure to Monitor Drug Regimens and Side Effects
Penalty
Summary
The facility failed to ensure that the drug regimens for three residents were free from unnecessary drugs by not adequately monitoring for side effects and adverse consequences. Resident 42 was prescribed Eliquis and clopidogrel for atrial fibrillation and gabapentin for epilepsy. However, there was no documentation of monitoring for signs and symptoms of bleeding and bruising associated with the use of Eliquis and clopidogrel, nor was there monitoring for signs of drug toxicity related to gabapentin. This lack of monitoring was noted in the resident's Medication Administration Record (MAR) for March 2025, despite the care plan indicating the need for such monitoring. Resident 79, who was prescribed atorvastatin for hyperlipidemia, did not have a lipid panel ordered or conducted since admission to the facility. The care plan for Resident 79 indicated the need to monitor the effect of the medication and perform laboratory work, but the clinical chart lacked any lipid laboratory results. This oversight was confirmed during an interview with a Licensed Vocational Nurse and the Director of Nursing, who acknowledged the importance of monitoring lipid levels to ensure the effectiveness of atorvastatin. Resident 40, who was on apixaban for deep vein thrombosis prophylaxis, did not have an order for monitoring adverse effects of the medication. The care plan highlighted the risk of adverse effects from this high-risk drug class, yet there was no monitoring for potential bleeding. The Director of Nursing confirmed that staff should have obtained an order for monitoring adverse effects and emphasized the importance of such monitoring to prevent complications. The facility's policies and procedures also underscored the need for monitoring adverse drug reactions and ensuring residents maintain the highest practicable level of functioning.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens for five residents were free from unnecessary psychotropic medications. Resident 95 was admitted with diagnoses including dementia, generalized anxiety disorder, and major depressive disorder. The resident was prescribed lorazepam PRN for restlessness or shortness of breath, but the order was not transcribed correctly, lacked an end date, and was administered beyond the 30-day limit without proper evaluation or documentation. This oversight placed the resident at risk of receiving unnecessary medication without a documented rationale for its continued use. Resident 79 was prescribed mirtazapine and divalproex for mood disorders, but there was no specific, measurable target behavior documented for their use. Despite the absence of depressive symptoms or poor appetite, there was no attempt for a Gradual Dose Reduction (GDR) or documented clinical rationale for continuing the medications. Similarly, Resident 89 was prescribed fluoxetine for depression without a specific behavior to monitor, leading to potential unnecessary use of the medication. The lack of specific behavior monitoring could result in inaccurate assessments of the medication's effectiveness. Resident 8 was administered sertraline and divalproex sodium without documented informed consent from the resident's representative. The orders lacked specific behaviors to monitor, which could lead to inaccurate monitoring and unnecessary medication administration. Resident 63 was prescribed alprazolam PRN for anxiety before dental procedures without a stop date, increasing the risk of unnecessary medication use. The facility's failure to adhere to its policies on psychotropic medication use and informed consent contributed to these deficiencies.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12.5% error rate during a survey. This deficiency affected two residents, who experienced medication administration errors. Resident 21 received carvedilol at a different time than prescribed, was given an incorrect form of multivitamin, and did not receive polyethylene glycol as ordered. Resident 77 also received carvedilol at a time different from the physician's order. The errors were observed during medication administration rounds. LVN 1 administered carvedilol to Resident 77 at 9:15 a.m., outside the prescribed time frame of 7:15 a.m. with breakfast. LVN 3 administered carvedilol and an incorrect multivitamin to Resident 21 at 9:27 a.m., instead of the scheduled 7:15 a.m. with breakfast, and failed to administer polyethylene glycol. Both LVNs cited being busy with other residents as the reason for the delays and errors. Interviews with the LVNs and the Director of Nursing confirmed these errors and acknowledged the potential for adverse effects due to the deviations from prescribed medication schedules. The facility's policies require medications to be administered within a 60-minute window of the prescribed time, which was not adhered to in these instances. The facility's policy also emphasizes the importance of following physician orders to prevent medication errors and adverse consequences.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. Three residents, identified as Residents 107, 17, and 48, were affected by this deficiency. The primary issue was the failure to rotate subcutaneous insulin administration sites as per physician's orders, manufacturer's guidelines, and accepted professional standards. This oversight was identified during a review of the residents' medication administration records and confirmed through interviews with nursing staff and the Director of Nursing (DON). Resident 17, who was readmitted to the facility with diagnoses including type 2 diabetes mellitus and dementia, had physician's orders for insulin lispro that required site rotation. However, the medication administration records indicated that the insulin was repeatedly administered in the same area, contrary to the physician's orders and facility policy. Similarly, Resident 48, with diagnoses of type 2 diabetes mellitus and congestive heart failure, also had orders for insulin administration that were not followed correctly, as the injection sites were not rotated as required. Resident 107, admitted with type 2 diabetes mellitus and chronic kidney disease, also experienced the same issue with insulin administration. The records showed multiple instances where the insulin was administered in the same site without rotation. Interviews with the nursing staff and the DON confirmed that the failure to rotate injection sites was a medication error, as it did not comply with the physician's orders, manufacturer's guidelines, or professional standards. This deficiency had the potential to cause adverse effects such as bruising, lipodystrophy, and cutaneous amyloidosis.
Failure to Update Staffing Plan Leads to Medication Delays
Penalty
Summary
The facility failed to revise and provide a current staffing plan in the Facility's Assessment, which evaluates the resident population and determines the necessary resources to care for residents competently during both day-to-day operations and emergencies. This deficiency resulted in residents receiving medications later than scheduled, specifically affecting Residents 21 and 77, who received their carvedilol doses after the prescribed time. The delay in medication administration was acknowledged as a medication error by the Licensed Vocational Nurses (LVNs) involved. Interviews with LVNs revealed that the delay in administering medications was due to the high number of residents assigned to each nurse, which exceeded the facility's assessed staffing ratio of 1 LVN to 24 residents. LVNs reported being unable to administer medications within the required timeframe due to being occupied with other tasks such as handoffs, resident rounds, and medication cart checks. The facility's policy allowed a 60-minute window for medication administration, but the LVNs were unable to meet this requirement due to their workload. The facility's assessment, dated 12/1/2024, indicated a staffing need of 1 LVN per 24 residents during the day shift. However, the actual staffing ratios between 3/11/2025 and 3/13/2025 were significantly higher, with LVNs being assigned to 36 to 45 residents each. The Administrator acknowledged that a new assessment was needed when the facility's acuity changed, but no new assessment had been conducted since 12/1/2024. The failure to maintain the assessed staffing ratio contributed to the delay in medication administration and the resulting medication errors.
Inadequate Linen Cart Covers Compromise Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring that clean linens were adequately protected from environmental contaminants. During observations and interviews, it was found that all 17 clean linen carts were covered with a permeable, loosely woven material, which allowed air and water to pass through. This material was not suitable for preventing contamination from dust and liquids, as confirmed by the Infection Preventionist and the Housekeeping Supervisor. The Director of Nursing acknowledged that the linen cart covers had not been changed since the last recertification survey and recognized the importance of using non-porous covers to maintain linen cleanliness. The facility's current practice involved using bleach wipes for cleaning the linen carts, which were only recommended for hard, non-porous surfaces, according to the Safety Data Sheet. The Manufacturer's Guidelines for the linen cart covers also indicated that the material was not suitable for the facility's cleaning methods. The facility's policy on cleaning and disinfection required adherence to CDC and OSHA standards, which were not met due to the use of porous linen cart covers. This deficiency had the potential to spread infections and illnesses among residents and staff.
Failure to Honor DNR Order for a Resident
Penalty
Summary
The facility failed to honor the Do Not Resuscitate (DNR) order for Resident 115, which resulted in a violation of the resident's rights to dignity and respect. Resident 115, who had been diagnosed with metabolic encephalopathy, sepsis, and dementia, was found unresponsive with no vital signs. Despite having a DNR order in place, facility staff initiated cardiopulmonary resuscitation (CPR) and called emergency services, who continued resuscitation efforts until the resident was pronounced deceased. The deficiency occurred because the Preferred Intensity of Care (PIC) Authorization/Decisions form, which indicated the resident's DNR status, was not properly filed in the resident's current chart upon readmission. The MDS Nurse and Social Services Director acknowledged that the form was mistakenly filed in the resident's old chart, leading to the assumption that the resident was full code status. This oversight meant that the resident's wishes were not followed, and CPR was administered contrary to the DNR order. Interviews with facility staff, including the MDS Nurse, Social Services Director, and Director of Nursing, revealed a lack of adherence to the facility's policies and procedures regarding DNR orders. The staff admitted that the resident's preferred intensity of care should have been verified and documented in the current chart upon readmission. The facility's policies clearly state that DNR orders must be followed unless a signed request to end the order is provided, which was not the case for Resident 115.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure the call light was within reach for two residents, leading to a deficiency in accommodating resident needs and preferences. Resident 46, who was admitted with multiple diagnoses including dementia and a history of falls, was observed with the call light hanging on the wall, out of reach. The resident's care plan specifically indicated that the call light should be within easy reach to encourage its use for assistance. During an observation, the Infection Preventionist acknowledged the oversight and confirmed that the call light should have been placed within reach for dignity reasons and to allow the resident to call for help if needed. Similarly, Resident 107, who was alert and oriented, was found with the call light resting on the floor beside the bed. The Assistant Director of Staff Development and a Registered Nurse both confirmed that the call light should always be within reach to allow the resident to call for help when necessary. The Registered Nurse also noted that if the call light frequently falls, it should be clipped to the bed sheet to prevent it from becoming a trip hazard and to ensure it remains accessible. The Director of Nursing reviewed the facility's policies and procedures, which emphasized the importance of having the call light accessible to residents to ensure timely responses to their needs. The failure to adhere to these policies resulted in a deficiency, as the call lights were not within reach for the residents, potentially delaying care and services.
Failure to Assist with Advance Directives for Two Residents
Penalty
Summary
The facility failed to offer assistance with formulating an Advance Directive (AD) to two residents, Residents 79 and 97, upon their admission. Resident 79 was originally admitted on January 29, 2024, and readmitted on September 17, 2024, with diagnoses including dementia and hemiplegia following a stroke. The resident's records indicated severely impaired cognition and a need for substantial assistance with daily activities. Despite these conditions, the facility did not document any inquiry or assistance offered to the resident's representative regarding the presence or formulation of an AD. Similarly, Resident 97, admitted on June 26, 2024, with Alzheimer's Disease and other mental health conditions, also had severely impaired cognition and required maximal assistance with daily activities. The facility's records for Resident 97 also lacked documentation of any inquiry or assistance offered to the resident's representative about an AD. Interviews with the Social Services Director and a Registered Nurse confirmed that the necessary steps to inquire about or assist with ADs were not taken for either resident. The facility's policy on Advance Directives, last reviewed on September 27, 2024, mandates that the social services director or designee inquire about the existence of any written ADs upon admission. The policy also requires that information about ADs be prominently displayed in the medical record. However, the facility failed to adhere to this policy, as evidenced by the lack of documentation and inquiry regarding ADs for both residents, potentially impacting their care in emergencies.
Deficiencies in Providing a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents, leading to deficiencies in their living conditions. Resident 79, who has severe cognitive impairment and is at high risk for falls, was found to have a floor mat with tears covered by black tape and one tear that was not covered. Despite the presence of a physician's order for bilateral floor mats to prevent injury, the staff did not notify the maintenance department to replace the damaged mat, compromising the resident's safety and the homelike environment. Resident 70, who is dependent on staff for daily activities and has limited cognitive abilities, was found in a room with a broken baseboard and windowsill, exposing nails and broken concrete. The Maintenance Director had left the room in this condition for about a week, believing it was not unsafe. Additionally, red stenciled letters were observed on the wall, which were unrelated to the resident and contributed to an institutional rather than homelike setting. The Director of Nursing acknowledged that these conditions were hazardous and not in line with the facility's policy for a homelike environment. The facility's policy on providing a homelike environment emphasizes safety, cleanliness, and personalization, which were not upheld in these cases. The deficiencies observed in the residents' rooms had the potential to negatively impact their psychosocial well-being and comfort, as the facility failed to maintain a clean and orderly environment as required by their policy.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy and return form to a resident's representative when the resident was transferred to a general acute care hospital. This deficiency was identified during a review of the records for a resident who was admitted to the facility with diagnoses including metabolic encephalopathy, sepsis, and pneumonitis. The resident was transferred to the hospital due to coffee ground emesis, hypotension, and tachycardia, with a seven-day bed hold indicated in the order summary report. However, the facility did not provide the required written notification of the bed-hold policy to the resident or their representative at the time of transfer. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the notification was not provided. The facility's policy requires that residents and their representatives be informed in writing of the bed-hold policy both in advance of any transfer and at the time of transfer, or within 24 hours in the case of an emergency. The failure to provide this notification could result in the resident's responsible party being unaware of the bed-hold policy, potentially leading to the resident being transferred to another skilled nursing facility not of their preference.
Failure to Adhere to DNR Order for Resident
Penalty
Summary
The facility failed to adhere to a Do Not Resuscitate (DNR) order for a resident, identified as Resident 115, who was administered cardiopulmonary resuscitation (CPR) despite having a documented DNR order. The resident had been admitted with conditions including metabolic encephalopathy, sepsis, and dementia, and was not capable of making decisions regarding their care. The resident's representative had authorized no CPR, consistent with the resident's wishes, as documented in the Preferred Intensity of Care (PIC) Authorization/Decisions form. The deficiency occurred when Resident 115 was found unresponsive with no vital signs, and CPR was initiated by facility staff. The PIC Authorization/Decisions form, which indicated the resident's DNR status, was not filed in the current chart upon the resident's readmission, leading staff to consider the resident as full code status. The Social Services Director acknowledged the oversight in not verifying the resident's previous PIC Authorization/Decisions form, which resulted in the administration of CPR contrary to the resident's documented wishes. Interviews with facility staff, including the MDS Nurse and the Director of Nursing, revealed that the facility's policy and procedure for handling DNR orders were not followed. The facility's policy required that DNR orders be respected unless a signed request to end the DNR order was provided by the resident or their legal surrogate. The failure to properly document and communicate the resident's DNR status led to the violation of the resident's rights and preferred treatment wishes.
Failure to Conduct Change of Condition Assessment
Penalty
Summary
The facility failed to ensure a comprehensive assessment for a resident who experienced a significant change of status. The resident, who had been admitted with diagnoses including metabolic encephalopathy, acute and chronic respiratory failure, and the presence of vascular implants and grafts, was discharged to a General Acute Care Hospital due to abnormal laboratory results indicating elevated white blood cells and blood urea nitrogen levels. Despite these significant changes, no change of condition assessment was performed on the day of the transfer, as confirmed by the review of records and interviews with facility staff. The lack of a change of condition report was acknowledged by both a Registered Nurse and the Director of Nursing during interviews. The facility's policy requires that such assessments be conducted to document and communicate the resident's condition and the interventions provided prior to transfer. This omission in documentation and communication had the potential to negatively affect the provision of necessary care and services to the resident.
Failure in Catheter Care Leading to UTI Risk
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters, leading to a potential risk of urinary tract infections (UTIs) for two residents. Resident 272, who was admitted with obstructive and reflux uropathy, had a suprapubic catheter that was observed with a loop in the tubing, preventing proper urine drainage. Despite having a care plan that required maintaining proper alignment of the catheter to promote drainage, the tubing was found coiled with urine inside, which could lead to backflow and infection. Interviews with staff confirmed that the catheter should be positioned to allow free urine flow, and the facility's policy emphasized keeping the catheter and tubing free of kinks. Similarly, Resident 371, admitted with benign prostatic hyperplasia and obstructive uropathy, also had issues with catheter care. The resident's foley catheter tubing was observed coiled, not promoting proper drainage, contrary to the care plan's intervention to maintain proper alignment. Staff interviews reiterated the importance of preventing loops in the tubing to avoid urine backflow and potential UTIs. The facility's policy on catheter care, reviewed in 2024, highlighted the need to check the catheter frequently to ensure it is not kinked and is draining properly. The observations and interviews indicate a failure in adhering to the facility's catheter care policy, which aims to prevent catheter-associated complications, including UTIs. Both residents had catheter tubing that was not properly aligned, posing a risk of urine backflow and infection. The staff acknowledged the importance of maintaining catheter tubing without loops or kinks, yet the deficiency persisted, highlighting a lapse in the implementation of care protocols.
Failure to Administer Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to provide nutritional support as ordered for a resident, identified as Resident 42, who was at risk of weight loss. The resident, who had been readmitted to the facility with diagnoses including chronic obstructive pulmonary disease, chronic pain syndrome, and Parkinson's disease, had a physician's order for Ensure, a nutritional supplement, to be given twice daily. However, during an observation and interview, it was noted that the Ensure was not present in the resident's room, and the resident reported a significant weight loss from 195 pounds to 144 pounds since admission. The resident stated that the Ensure was usually brought to him after breakfast but before lunch, yet it was not provided on the day of the observation. Licensed Vocational Nurse (LVN) 1 confirmed that the Ensure had not been given to the resident as scheduled and acknowledged the oversight. The Director of Nursing (DON) stated that the Ensure required a doctor's order and should be administered as prescribed. The facility's policy and procedure for physician orders and snack service emphasized the importance of following specific orders and documenting the provision of snacks, including nutritional supplements like Ensure. The failure to provide the Ensure as ordered had the potential to contribute to further weight loss for the resident.
Deficient IV Fluid Administration Practices
Penalty
Summary
The facility failed to ensure the proper administration of intravenous (IV) fluids consistent with professional standards of practice for two residents. For Resident 269, the facility did not change a loose and soiled dressing on a peripherally inserted central line catheter (PICC line) in a timely manner. The resident, who was admitted with conditions including osteomyelitis and anxiety disorder, had a care plan indicating that dressings should be changed every seven days or as needed if they became wet, loose, or soiled. Despite this, the dressing was observed to be loose and soiled after the resident had a shower, and it was not changed promptly, which was confirmed by both a registered nurse (RN) and the Director of Nursing (DON). For Resident 15, the facility failed to place a sterile injection cap over the injection port of a peripheral intravenous line (PIV). The resident, who had been readmitted with pneumonia, Alzheimer's Disease, and major depressive disorder, had a physician's order to flush the PIV with normal saline and to change the dressing as needed. During an observation, it was noted that the needleless injection port did not have a sterile injection cap, which was acknowledged by an RN and the DON. The lack of a sterile injection cap after use was against the manufacturer's guidelines, which state that a new cap should be placed on the needleless connector after each use. These deficiencies were observed during a random inspection and were confirmed through interviews with facility staff and a review of the facility's policies and procedures. The facility's failure to adhere to established protocols for IV care placed both residents at risk for complications such as infection, as noted in the report.
Failure to Conduct Quarterly Bed Rail Safety Assessment
Penalty
Summary
The facility failed to conduct a quarterly assessment for the risk of entrapment from bed rails for Resident 88, who was admitted with diagnoses including dementia, age-related physical debility, and a history of falling. The resident was on fall precaution and did not have the capacity to make medical decisions. Despite the resident's impaired cognition and high risk for falls, the last Side Rail Safety/Entrapment Assessment was conducted over a year ago, on 2/21/2023. The facility's policy required quarterly assessments to ensure the appropriateness and safe use of bed rails, which were being used as a restraint for Resident 88. The resident's care plan indicated the need for quarterly assessments by the interdisciplinary team to evaluate the appropriateness of the restraint. However, this was not adhered to, as confirmed by RN 1 during an observation and interview, who acknowledged the lapse in conducting the necessary assessments. The Director of Nursing confirmed that the facility's protocol required a physician's order, a safety/entrapment assessment, informed consent, and a care plan before using side rails as a restraint. The facility's policy on bed safety and bed rails outlined the need for comprehensive assessments, including factors such as medical diagnosis, cognition, and mobility, to determine the risk of entrapment. The failure to perform these assessments predisposed Resident 88 to potential risks associated with bed rail use.
Failure to Properly Label Intravenous Medication
Penalty
Summary
The facility failed to ensure that intravenous meropenem, a medication used to treat bacterial infections, was labeled with the resident's name, which is a requirement for safe medication administration. This deficiency was identified during the review of a resident who had been admitted and readmitted to the facility with diagnoses including malignant neoplasm of the prostate and a urinary tract infection. The resident was observed receiving meropenem intravenously, and the medication bag was labeled with the medication name, dose, and nurse's initials, but not the resident's name. The Registered Nurse (RN) acknowledged the oversight, stating that the pharmacy had not delivered the medication, so it was taken from the emergency medication kit and should have been labeled with the resident's name. The Director of Nursing (DON) confirmed that the facility's policy and procedures for medication labeling were not followed, which require the resident's name to be included on the label to ensure the correct administration of medication. The facility's policies emphasize the importance of labeling to prevent medication errors, but in this instance, the policy was not adhered to, leading to the potential for medication administration errors.
Failure to Follow Up on Abnormal Lab Results
Penalty
Summary
The facility failed to follow up with the endocrinologist regarding a resident's hemoglobin A1C test result, which was reported to the facility. The resident, who was admitted with diagnoses including diabetes mellitus with diabetic neuropathy, congestive heart failure, and chronic kidney disease, had an HbA1c test result of nine percent, indicating poor blood sugar control. Despite the test result being documented and the attending physician being notified, there was no follow-up with the endocrinologist to determine if medication adjustments were necessary for the resident's diabetes management. The facility's policy and procedures require that the attending physician be promptly notified of diagnostic test results, and the director of nursing services or charge nurse is responsible for this notification. However, the MDS Nurse noted that there was no documentation of follow-up with the endocrinologist the day after the test result was received. This lack of follow-up placed the resident at risk for complications associated with uncontrolled blood sugar levels.
Failure to Label Cranberry Juice in Kitchen
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices by not labeling a pitcher of cranberry juice with the date it was poured. During a kitchen observation tour, a surveyor, along with the Dietary Manager (DM), found the pitcher stored in the kitchen refrigerator without a date label. The DM acknowledged that the staff should have dated the pitcher to ensure the juice was fresh and not past its best use-by date, which could prevent food-borne illnesses. The Director of Nursing (DON) also confirmed that the dietary staff should have labeled the pitcher to track the age of the juice, as consuming old juice could lead to stomach problems such as nausea, vomiting, and diarrhea for residents. A review of the facility's policy and procedure titled 'Food Receiving and Storage' indicated that all foods stored in the refrigerator or freezer should be covered, labeled, and dated with a use-by date. This policy was not followed, leading to the deficiency observed by the surveyors.
Inaccurate Elopement Risk Assessment Documentation
Penalty
Summary
The facility failed to maintain medical records within accepted professional standards for a resident reviewed for accidents by inaccurately completing the elopement risk assessment. The resident, who was originally admitted in 2021 and readmitted in 2024, had diagnoses including cerebral infarction and dementia, which impaired their cognitive abilities and required substantial assistance with daily activities. Despite the resident's condition indicating a risk for elopement, the elopement risk assessments conducted in October 2024 and January 2025 inaccurately documented the resident as not being at risk, despite a calculated score indicating otherwise. During interviews, MDS Nurses acknowledged the documentation error, noting that the electronic health record system automatically calculated the risk score based on the resident's condition. The facility's policy required documentation to be objective, complete, and accurate, which was not adhered to in this case. The inaccurate documentation had the potential to lead to confusion regarding the resident's current status, as the summary of the review did not reflect the resident's true risk for elopement.
Failure to Ensure Fair Arbitration Process
Penalty
Summary
The facility failed to ensure the fairness and integrity of the binding arbitration process for a resident, identified as Resident 3, who was admitted on 3/24/2007 and readmitted on 9/4/2024. The resident had diagnoses including metabolic encephalopathy, acute on chronic respiratory failure, and COPD. Despite having expressive aphasia and moderately impaired cognition, the resident was assessed to have the capacity to understand and make decisions. The arbitration agreement signed by the resident's representative on 11/14/2023 did not provide for the selection of a neutral arbitrator agreed upon by both parties or a venue convenient to both parties. During interviews and record reviews, it was revealed that the Admission's Coordinator and the Administrator acknowledged the importance of the arbitration agreement, which involves giving up the constitutional right to a jury or court trial. The facility had updated its arbitration agreement in 2019 to include provisions for a neutral arbitrator and a convenient venue, but Resident 3's agreement, signed in 2023, used an outdated version from 2007 that lacked these provisions. The Admission's Coordinator, who was not employed at the facility in 2023, could not explain why the outdated version was used. The Administrator confirmed that the facility's process was not followed, as the arbitration agreement signed by Resident 3's representative did not include the necessary elements of a neutral arbitrator and a convenient venue. The facility did not have a specific policy regarding arbitration agreements but relied on the revised 2019 agreement and an information form to guide the process. The failure to use the updated agreement potentially placed the resident in a less favorable position during arbitration.
Failure to Ensure Proper Hospice Documentation and Communication
Penalty
Summary
The facility failed to ensure consistent and necessary care for a resident receiving hospice services. Specifically, the hospice doctor did not sign the initial Certification of Terminal Illness (CTI) for the resident, which is required to certify that the patient is terminally ill with a prognosis of six months or less. Additionally, the hospice provider did not provide the updated hospice plan of care to the facility upon completion of the resident's CTI recertification. This lack of documentation and communication had the potential to negatively impact the resident's physical comfort and psychosocial well-being. The resident, who was admitted to the facility with diagnoses including dementia, generalized anxiety disorder, and major depressive disorder, was under the care of a hospice provider. The facility's policy requires that the hospice provider manage the resident's care related to the terminal illness, including providing an appropriate hospice plan of care. However, the absence of the hospice doctor's signature on the CTI and the failure to provide the updated plan of care created a communication barrier between the hospice and the facility, potentially resulting in a delay or lack of necessary care and services for the resident.
Failure to Timely Complete MDS Assessment
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) Assessment for a resident in a timely manner, as required by regulations. Specifically, the MDS Quarterly Assessment for a resident admitted on 9/20/2024 with diagnoses including type II diabetes mellitus, major depressive disorder, and hypertension, was not completed within the required timeframe. The assessment, which should have been completed by 1/10/2025, was instead completed on 1/13/2025, as indicated by the registered nurse assessment coordinator's signature. This delay was confirmed during a review of the Final Validation Report, which showed the assessment was completed more than 14 days after the assessment reference date of 12/27/2024. Interviews with the MDS Nurse and the Director of Nursing revealed that the delay in completing the MDS Assessment could lead to a delay in reporting the resident's health status and quality measures. The facility's policy and procedure, as well as the CMS Long-Term Care Facility Resident Assessment Instrument Manual, require that MDS assessments be completed and submitted within specific timeframes to ensure accurate and timely reporting of residents' health status. The failure to adhere to these timeframes constitutes a deficiency in the facility's compliance with regulatory requirements.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential impacts on their care plans and services. For one resident, the MDS Entry assessment was incorrectly coded with the wrong admission date, despite the resident being admitted for rehabilitation and skilled nursing services under Medicare A. The MDS Nurse acknowledged the error during a review and interview, noting that the incorrect entry could affect billing and the resident's health status documentation. The Director of Nursing emphasized the importance of accurate MDS assessments to prevent duplication and ensure the correct resident information is recorded. For another resident, the MDS assessment was not accurately coded to reflect the resident's discharge status. The resident left the facility against medical advice, but the MDS assessment did not indicate the discharge date or the discharge return not anticipated status. This oversight was identified during a review with the MDS Nurse, who admitted the error could cause confusion regarding the resident's status and potentially delay necessary care and services. The facility's policy requires all individuals completing portions of the MDS to certify the accuracy of their entries, which was not adhered to in these cases.
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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