Sierra View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baldwin Park, California.
- Location
- 14318 Ohio Street, Baldwin Park, California 91706
- CMS Provider Number
- 056466
- Inspections on file
- 28
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Sierra View Care Center during CMS and state inspections, most recent first.
Call lights were not kept within reach for two residents. One resident with glaucoma, myopathy, severely impaired cognition, and high fall risk was observed in bed unable to find the call light, and staff later found a call pad under the pillow. Another resident with hemiplegia, hemiparesis, dementia, and severe cognitive impairment had the call light placed on the side of the bed next to the pillow even though the resident could not move the left hand and staff stated it should have been placed by the right hand for access.
Incomplete and Non-Individualized Care Plans: The facility failed to create and carry out resident-centered CPs for three residents. One resident with blindness and severe cognitive impairment had an activity CP that still referenced family participation even though no family contacts existed. Another resident receiving IV ampicillin had CP interventions that did not match the resident’s actual IV status and lacked documented monitoring for nephrotoxicity and hearing changes. A third resident developed BLE scaling and stiffness after A&D ointment use, but no CP or SBAR/COC addressed the change in condition.
Catheter care was not provided as ordered for two residents with indwelling catheters. One resident with a suprapubic catheter and another resident with a Foley catheter were observed in bed with tubing not secured to the thigh or connected to the securement device, despite orders and care plans directing catheter stabilization. RN, LVN, TN, and the DON all confirmed the tubing should have been secured to prevent pulling, dislodgement, and injury.
GT site care and feeding precautions were not followed for two residents with GTs. One resident with dementia and severe cognitive impairment had a GT dressing left unchanged despite orders for daily cleansing and dressing changes, and drainage was observed at the site. Another resident was observed lying flat in a supine position while receiving continuous GT feeding, even though the CP and OSR required HOB elevation during tube feeding; RN and DON confirmed the ordered positioning was not being followed.
Outdated food items were found in multiple kitchen storage areas, including an open loaf of wheat bread, baking soda, tortillas, and a tray of grilled cheese sandwiches and pizzas. The DS stated each item should have been discarded because it was past its use-by date, and the IPN stated food beyond the use-by date was not acceptable for residents and could cause food-borne illness. Facility P&Ps required date marking and discarding outdated food products.
An RN failed to timely document a resident’s respiratory assessment after assessing lung sounds and breathing for chest congestion, and also failed to timely sign an IVAR for another resident’s scheduled IV ampicillin dose. The DON stated assessments and medication administration should be documented at the time of service, and staff said the delays occurred because the RN was helping another shift and was busy.
A resident with a midline catheter had an undated dressing after RN care, despite facility policy requiring the dressing to be labeled with the date of change. In a separate event, a resident on EBP for a GT and ESBL history received direct hygiene care from a CG without the required gown and gloves, even though the care plan, order, and staff interviews confirmed PPE was required for high-contact care activities.
A resident’s ampicillin IV bag was observed hanging at the bedside with the resident’s first and last name and room number uncovered, and on one occasion the bag was unattended and not connected to the resident. RN 1 stated the information was not covered and could be seen by unauthorized people, and the DON stated housekeeping and maintenance staff did not need access to residents’ health information. The resident had osteomyelitis and bacteremia, with the H&P noting capacity for medical decisions and the MDS showing moderately impaired cognition and need for staff assistance with multiple ADLs.
A resident with hyperlipidemia, anemia, and dementia had an elevated triglyceride level and an RD recommendation for omega three 1,200 mg daily. RN stated the recommendation was received but was not followed up with the primary physician, and the DON stated there was no specific timeframe for acting on RD recommendations even though they should be acted on as soon as possible. The care plan noted nutritional problems and included RD evaluation and diet change recommendations.
A resident receiving O2 therapy and nebulizer treatments had the nebulizer mask left hanging on the bedrail and the O2 tubing left on the bed when the resident was not in the room. The resident had diagnoses including ARF with hypoxia and HF, and the care plan and orders included O2 via NC and albuterol nebulizer treatments. The LVN and DON stated respiratory supplies should be stored in a clear bag when not in use for infection control, and the facility policy required respiratory equipment to be covered when not in use.
A resident with intact cognition, multiple fall‑related diagnoses, and a history of hoarding was care‑planned for assistance in keeping the room clean and clutter‑free, but surveyors observed the room heavily cluttered around and on the bed, with access blocked on one side and clothes and personal items piled on surfaces and the floor. Staff reported the room had been cluttered for years and that they avoided touching the resident’s belongings, despite facility policies requiring belongings to be kept neat and the environment safe and homelike. Surveyors also found multiple packs of cigarettes in an open bedside drawer and Benadryl capsules on the bed and in the resident’s jacket pocket, even though there was no IDT assessment or order for self‑administration and no locked bedside storage, resulting in unsecured medications and cigarettes at the bedside.
The facility failed to complete Advance Directive documentation for three residents, risking non-compliance with their treatment preferences. One resident's form was incomplete, another's AD was missing from the chart, and a third's form did not indicate if an AD was executed. The Social Services Director and Director of Nursing acknowledged these oversights, which could lead to inappropriate care.
The facility failed to create individualized care plans for two residents with PTSD, despite their diagnoses and observed behaviors. Both residents lacked care plans addressing PTSD, contrary to the facility's policy on Trauma Informed Care, which emphasizes minimizing triggers and re-traumatization.
The facility failed to follow infection control policies for three residents, leading to potential infection spread. A CNA did not wear the required PPE while changing a resident on EBP, and another resident lacked proper signage for contact isolation. Staff acknowledged the importance of PPE, and the DON emphasized reassessment and proper cohorting for residents on transmission-based precautions.
The facility failed to obtain informed consent for the use of a wander guard alarm on a resident with severe cognitive impairment and anxiety, violating their rights and potentially causing psychological distress. Despite the facility's policy requiring consent for such devices, there was no documented evidence of consent being obtained, as confirmed by interviews with an LVN and the DON.
A resident with dementia and fall risk had a call light out of reach, contrary to their care plan and facility policy. The resident was unaware of the call light's location, and staff confirmed it should be accessible. The facility's policy requires call lights to be within reach.
A facility failed to complete the required Level I PASRR for a resident readmitted with severe cognitive impairment and multiple diagnoses, including cancer and bipolar disorder. The resident was in the facility for over 30 days without the necessary PASRR I evaluation, which should have triggered a PASRR II. Staff interviews revealed a lapse in the process of coordinating PASRR evaluations, contrary to the facility's policy.
A facility failed to develop a care plan for a resident prescribed Zoloft for depression, despite the resident's diagnoses of major depressive disorder and hypertension. The absence of a care plan was confirmed by the RN Supervisor and DON, who acknowledged that a plan should guide staff in monitoring the medication's effectiveness. This oversight was contrary to the facility's policy requiring comprehensive care plans with measurable objectives and timeframes.
A resident with moderately impaired cognition and orthopedic aftercare was not provided with effective constipation management for five days. Despite complaints and the known side effect of Norco, the facility delayed administering Milk of Magnesia (MOM) and failed to document its effectiveness or follow up with additional treatment. The facility's policy on monitoring and reporting adverse reactions was not followed, leading to a delay in necessary care.
A facility failed to follow its catheter care policy for a resident with an indwelling catheter. The resident's catheter port was visibly soiled, and there was no securement device in place, contrary to the care plan and physician's orders. Staff interviews confirmed these oversights, which could increase the risk of infection and injury.
A resident receiving tube feeding through a gastrostomy tube was observed to have the feeding running while being changed in a supine position, contrary to the care plan requiring head elevation to prevent aspiration. The LVN and CNA involved acknowledged the oversight, and the DON confirmed the need to pause feeding during such procedures. The resident had a history of cerebral palsy, paraplegia, and aphasia, and was at high risk for complications.
A facility failed to ensure that pharmacy recommendations for a resident were signed and dated by the attending physician, as required for proper medical care. The SNPRs for September and December 2024 were not appropriately signed, and the last physician note was from December 28, 2024. The resident had severe cognitive impairment and used a wheelchair. The DON confirmed the importance of signed SNPRs for indicating physician evaluation.
The facility did not post nurse staffing information in a prominent place accessible to all residents and visitors. Observations showed the information was only available at the reception desk near Nursing Station A, leaving it inaccessible to those near Nursing Station B. The Director of Staff Development confirmed the limited posting and acknowledged the need for additional postings to comply with the facility's policy.
A facility failed to obtain informed consent for Trazodone 50 mg prescribed for insomnia in a resident with intact cognitive abilities. The resident did not sign the Physician Document of Informed Consent, indicating that the risks, benefits, and alternatives of the medication were not discussed, contrary to the facility's policy.
A resident with dementia and bipolar disorder was left alone with a family member during a visit, despite being on 1:1 monitoring for agitation. The family member hit the resident, causing physical harm, after the resident became verbally aggressive. The incident was reported after the resident called for a nurse, and the family member admitted to the abuse.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents. Resident 5 was admitted and later readmitted with diagnoses including unspecified glaucoma and myopathy. The resident’s records showed severely impaired cognition, dependence for toileting, showering, dressing, and footwear, and maximum assistance needed for oral and personal hygiene. The fall risk assessment identified the resident as high risk for falls due to disorientation, chairbound status, poor vision, and use of assistive devices. The care plan directed staff to place the call light within reach and encourage use of it for assistance as needed, with prompt response to requests for help. During observation on 4/21/2026, Resident 5 was awake and lying in bed but unable to find the call light. The resident stated the call light could not be found. A CNA also could not find the call light, and stated the resident could not ask for help if the call light was not within reach and accessible. An RN later found a call pad below the resident’s pillow and stated it should be within reach and next to the resident so the resident could call for assistance if needed. Resident 12 was admitted and readmitted with diagnoses including hemiplegia, hemiparesis, and dementia. The resident’s care plan identified an ADL self-care performance deficit related to hemiplegia, hemiparesis, and dementia, and included encouraging the resident to use the bell to call for assistance. The MDS showed severely impaired cognition and dependence or substantial/maximal assistance needs for multiple ADLs. During observation, Resident 12 was in bed with a splint on the left hand, and the call light was placed up on the left side of the bed next to the pillow. A CNA stated the resident could not move the left hand and that the call light should be placed next to the resident’s right hand where it could be reached.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans for three sampled residents. For one resident with blindness, bipolar disorder, generalized muscle weakness, and severely impaired cognition, the activity care plan still included an intervention to invite and encourage family members to attend activities even though the resident had no family or friend contacts. The resident required extensive assistance with eating, hygiene, dressing, bathing, toileting, and mobility, and the facility’s own records and staff interviews confirmed that the family-related activity intervention was not applicable to the resident. For another resident admitted with osteomyelitis and bacteremia, the care plan included interventions that did not match the resident’s actual condition and treatment needs. The resident was not receiving IV hydration, yet the IV therapy care plan included monitoring for signs and symptoms of fluid under or overload when on IV hydration. The same care plan also directed nursing staff to check for nephrotoxicity and hearing changes while the resident was receiving ampicillin IV every six hours, but nursing progress notes and the MAR did not show documentation of monitoring for nephrotoxicity or hearing changes during the period reviewed. For a third resident with peripheral vascular disease, osteoarthritis, and mental disorders, the resident reported scaling and stiffness of both lower extremities and toes after A&D ointment was applied to the bilateral lower extremities. Staff later observed flakiness and scaling, and the resident complained of tightness. The treatment nurse stated the condition was not reported to the physician, and the record review found no care plan addressing the complaint and no SBAR/change-of-condition documentation related to the skin changes and stiffness after the ointment application. Facility staff and the MDS coordinator stated that a specific care plan and SBAR/COC should have been developed for the resident’s condition.
Catheter tubing not secured for two residents
Penalty
Summary
Failure to provide appropriate catheter care was identified for two residents with indwelling catheters. Resident 6 was admitted with diagnoses including obstructive and reflux uropathy and benign prostatic hyperplasia, and the record showed an order for staff to apply a catheter stabilization device and check placement every shift. The care plan also identified a suprapubic catheter and directed staff to secure the catheter in place and check placement. During observation, Resident 6 was asleep in bed with the catheter tubing hanging on the left side of the bed. RN 1 stated the suprapubic catheter tubing did not have a catheter securement device and was not secured on the resident's thigh. Later, TN 1 stated the securement lock was on the resident's right thigh while the catheter tubing was hanging on the left side of the bed, and that the tubing should have been secured on the thigh to prevent pulling and injury. Resident 55 had diagnoses including CKD, HF, and dementia, and the care plan identified an indwelling catheter with high risk for catheter-related infection or trauma. The order summary showed an order to apply a catheter stabilization device to secure the Foley catheter in place. During observation, Resident 55 was lying in bed with a Foley catheter that was not connected to the securement device. LVN 1 stated the tubing should be secured to prevent it from being pulled out during movement and causing trauma or injury, and the DON stated the Foley catheter tubing should be secured on the resident's thigh to prevent pulling and dislodgement during bed mobility.
GT Site Care and Feeding Position Not Provided as Ordered
Penalty
Summary
Resident 3 had diagnoses including encounter for attention to a GT and dementia, with severely impaired cognition and dependence on staff for multiple activities of daily living. The physician’s order and care plan required GT site care with normal saline, pat dry, and a dry dressing every day shift, and the care plan also directed local GT site care as ordered and monitoring for signs and symptoms of infection. During observation, Resident 3 was found with a GT site dressing dated 4/19/2026 and light brown drainage at the site. RN 1 stated the dressing had not been changed the prior day, and the Treatment Nurse stated the dressing was forgotten and needed to be cleaned and changed daily as ordered to prevent infection. The DON stated licensed nurses were responsible for changing the GT site dressing daily as ordered. Resident 6 had diagnoses including encounter for attention to a GT, obstructive and reflux uropathy, and benign prostatic hyperplasia, and the care plan required head of bed elevation of at least 30 to 45 degrees during and after tube feeding. The order summary also directed staff to elevate the head of bed a minimum of 30 degrees at all times during administration of feedings or medications. During observation, Resident 6 was asleep, lying flat in bed in a supine position while connected to ongoing GT feeding at 50 ml/hr. RN 1 stated the resident should have had the head of bed elevated 30 to 45 degrees during feeding to prevent aspiration, and the DON stated the head of bed should have been elevated at least 30 degrees while on GT feeding.
Outdated Food Items Found in Kitchen Storage Areas
Penalty
Summary
Safe food storage practices were not maintained in the facility kitchen when surveyors found multiple food items past their use-by dates. During observation and interview with the Dietary Supervisor, an open loaf of wheat bread in the bread storage area was beyond its use-by date, an open plastic container of baking soda in dry storage was beyond its use-by date, an open pack of tortillas in the walk-in refrigerator was beyond its use-by date, and a tray of grilled cheese sandwiches and pizzas in the walk-in refrigerator was beyond its use-by date. In each instance, the Dietary Supervisor stated the items should have been discarded because they were past the use-by date. The Infection Preventionist Nurse stated that food beyond the use-by date should be thrown away because it could cause food-borne illnesses and that it was not acceptable to have food for residents beyond the use-by date. The Dietary Supervisor also stated that food beyond the use-by date could affect food quality, including bread losing moisture, and could cause nausea and vomiting. Facility policies titled Date Marking for Food Safety and Food storage both stated that food should be clearly marked with the date by which it must be consumed or discarded and that outdated food products should be discarded.
Delayed Documentation of Resident Assessment and IV Antibiotic Administration
Penalty
Summary
Licensed nursing staff failed to timely document required care in the medical record for two sampled residents. Resident 11 was admitted with diagnoses including COPD, asthma, and dementia, and the record showed moderately impaired cognition with dependence or assistance needed for several activities of daily living. During an observation on 4/21/2026, RN 1 assessed Resident 11’s lung sounds and breathing at the bedside for chest congestion, but the resident’s Nurses Progress Note did not contain documentation of that respiratory assessment when reviewed later. RN 1 stated the respiratory assessment should have been documented in the progress note and explained it was not documented because RN 1 was helping the 3 PM to 11 PM shift. The DON stated licensed nurses should document assessments after they are completed and that documentation is important for notifying the physician of any change in condition and for recording interventions for continuity of care. Resident 100 was admitted with osteomyelitis and bacteremia, and the record showed moderately impaired cognition with dependence or assistance needed for multiple activities of daily living. The resident had an active order for IV ampicillin 2 grams every six hours for bacteremia. The IV Administration Report showed RN 1 administered the 12 PM dose and signed it at 6:58 PM, and LVN 5 stated the dose was not documented timely. RN 1 stated the delay occurred because RN 1 was busy, and the DON stated it was not acceptable to document the medication administration at that time because the standard of practice was to document at the time of service.
Infection Prevention Failures With Midline Dressing Labeling and EBP PPE Use
Penalty
Summary
The facility failed to implement infection prevention procedures for Resident 100 by not ensuring a midline dressing was dated after it was changed. Resident 100 was admitted with diagnoses including osteomyelitis and bacteremia, had moderately impaired cognition, and required varying levels of staff assistance with hygiene, toileting, bathing, and mobility. The order summary required licensed staff to change the midline dressing on admission and as needed for site maintenance, and the IV administration record showed RN 3 changed the dressing on 4/20/2026 at 9 PM. However, observations on 4/21/2026 at 10:37 AM and again at 12:35 PM showed the midline dressing at the bedside and later in the dining room without a date. During interview, LVN 5 stated the dressing should be dated so it could be monitored daily, staff would know when it was changed, and when the next change was due, and said an undated dressing was not acceptable. LVN 5 also stated licensed nurses should check that the dressing was intact and dated, and that if a licensed nurse noted it was undated, the nurse should have informed the RN. The infection preventionist reviewed the photographs and stated the RN should have dated the midline site dressing during the dressing change, and RN 1 stated the RN should have changed and dated the dressing to prevent infection at the midline site. The facility policy required the nurse to label the dressing with the date the dressing change was performed. The facility also failed to follow Enhanced Barrier Precautions for Resident 101. Resident 101 was admitted with diagnoses including sepsis and attention to a gastrostomy tube, was placed on EBP because of the GT and a history of ESBL in urine, and had severely impaired cognition with dependence on staff for oral hygiene, toileting, dressing, footwear, and personal hygiene. The care plan and order summary required EBP for high-contact care activities, including hygiene and device care. During observation, CG 1 was cleaning the resident’s arms, face, and neck with a wet towel while not wearing a gown and gloves. LVN 6 stated visitors and CG 1 needed to wear the required PPE while providing care, and CG 1 acknowledged not wearing a gown and gloves despite knowing the purpose was to prevent spread of infection. The DON stated caregivers, visitors, and staff needed to wear gown, gloves, and masks before providing direct care to residents on EBP.
Uncovered Identifiable Information on IV Bag
Penalty
Summary
The facility failed to protect identifiable health information on an ampicillin IV bag for one sampled resident. Resident 100 was admitted with diagnoses including osteomyelitis and bacteremia, had capacity to make medical decisions per the H&P, and the MDS indicated moderately impaired cognition with needs for staff assistance with eating, oral hygiene, personal hygiene, toileting hygiene, showering/bathing, and mobility. The resident had an active order for ampicillin IV for bacteremia. During observations at the resident’s bedside, the ampicillin IV bag was hanging on the IV pole with the resident’s first and last name and room number uncovered. On one observation, the IV bag was unattended by facility staff and not connected to the resident. RN 1 stated the resident’s health information was not covered while the bag was hanging at the bedside and that it risked exposing the resident’s health information to unauthorized people. The DON stated housekeeping and maintenance personnel had access to residents’ rooms and did not need to know residents’ health information, and that everyone in the facility should protect residents’ health information in accordance with HIPAA. The facility policy stated personal and medical records should be kept confidential and should not be left unattended or viewable by unauthorized persons.
Failure to Act on RD Nutritional Recommendation
Penalty
Summary
The facility failed to ensure a dietary recommendation from the Registered Dietitian was acted upon for one sampled resident with hyperlipidemia, anemia, and dementia. The resident was admitted on 6/4/2024 and later readmitted, and the MDS dated 2/24/2026 indicated severely impaired cognition and dependence on staff for eating, toileting, bathing, dressing, and footwear. A triglyceride lab result dated 2/25/2026 showed a level of 226 mg/dl, above the normal level of below 150 mg/dl. A Nutritional Assessment dated 2/25/2026 documented the RD recommendation for omega three oral capsule 1,200 mg once daily for elevated triglycerides. The care plan revised 4/8/2026 identified nutritional problems related to hyperlipidemia, anemia, and dementia and included an intervention for the RD to evaluate and make diet change recommendations as needed. During interview and record review, RN 1 stated the RD recommendation was received on 2/25/2026, that it was RN 1's responsibility to carry it out, and that RN 1 did not follow up with the primary physician. The DON stated there was no specific timeframe to act on RD recommendations, but they should be acted upon as soon as possible; the facility policy stated supplements may be recommended by an RD and implemented post physician orders.
Respiratory Equipment Left Unstored
Penalty
Summary
The facility failed to provide necessary care and services for a resident receiving oxygen therapy and breathing treatments. The resident was admitted with diagnoses including acute respiratory failure with hypoxia, heart failure, and anxiety, and the care plan identified oxygen therapy related to shortness of breath with goals for the resident not to have signs and symptoms of poor oxygen absorption. The resident also had orders for oxygen via nasal cannula at 2 liters per minute and for albuterol nebulizer treatments every 6 hours as needed for shortness of breath or wheezing. During observation, the resident was not in the room and the nebulizer mask was left hanging on the bedrail while the oxygen tubing was left on the bed. The LVN stated that the nebulizer mask and oxygen tubing should be stored inside the transparent bag intended for respiratory supplies when not in use to prevent contamination and spread of infection. The DON also stated that all respiratory supplies should be placed inside the clear, transparent bag when not in use for infection control. The facility policy on oxygen administration stated that staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment, and that delivery services should be kept covered in a plastic bag when not in use.
Failure to Maintain Safe, Clutter‑Free Room and Control Bedside Medications and Cigarettes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and clutter‑free room environment for one resident, as well as failure to control access to medications and cigarettes in that resident’s room. The resident had a history of bilateral spinal stenosis, PTSD, repeated falls, lower back pain, tobacco use, and chronic pain syndrome, and was assessed as having intact cognition and capacity to make medical decisions. The resident required supervision or partial/moderate assistance with multiple ADLs, including toileting, bathing, and dressing. The care plan documented that the resident kept personal belongings on the floor, around the bed, and on top of the bed, refused to have staff clean and declutter the room, and was at risk for falls due to clutter. Interventions in the care plan included assisting the resident with keeping the area clean and clutter‑free, creating a regular cleaning schedule, encouraging the resident to participate in sorting/discarding items, and offering alternative measures to keep personal items in safe areas. Despite these identified risks and planned interventions, observations on the survey date showed the resident’s room remained full of clutter on and alongside the bed. Bags of clothes and other items were piled against the wall and bed on one side, blocking access to that side of the bed. On the other side and on top of the bed were various clothes and items including hats, napkins, a surgical mask, a comb, an apple, cookies, a clothes hanger, socks, gloves, and a stuffed animal, with the resident’s food tray sitting on or near the clothes. A three‑drawer dresser next to the bed had multiple items cluttered on top, the top drawer was open with several packs of cigarettes visible inside, and clothes were on the floor in front of the dresser. Staff interviews indicated that the resident’s room had been full of clutter for years, that the resident became angry if staff touched the resident’s belongings, and that staff generally did not touch the resident’s items, despite the facility’s policies requiring belongings to be kept in a neat and orderly fashion and the environment to be safe and homelike. In addition to the clutter and cigarettes, the resident had medications at the bedside without an order for self‑administration and without locked storage. The resident reported having a bottle of Benadryl capsules in the dresser for sinus problems and believed it had been stolen, then produced two pink and white Benadryl capsules from a jacket pocket and placed them on the bed. The DON confirmed seeing two Benadryl capsules on the resident’s bed and the ADM stated they were not aware the resident had Benadryl in the room or was self‑medicating. Both the ADM and DON acknowledged there had been no interdisciplinary team assessment authorizing the resident to self‑administer medications, despite facility policy stating that residents have the right to self‑administer medications only if the interdisciplinary team determines it is clinically appropriate. Social services documentation showed the resident had been educated about hoarding behaviors and the associated health, safety, and tripping hazards, and noted ongoing noncompliance with room cleanliness, but there were no further follow‑up notes for several weeks prior to the survey. These actions and inactions resulted in a cluttered, unsafe room environment with accessible cigarettes and unsecured medications at the bedside, contrary to the facility’s policies on resident personal belongings, safe and homelike environment, and resident rights to receive treatment and supports for daily living safely.
Failure to Complete Advance Directive Documentation
Penalty
Summary
The facility failed to adhere to its policy on Advance Directives (AD) for three residents, leading to potential issues in honoring their medical treatment preferences. For Resident 31, the Advance Directive Acknowledgement Form (ADA) was not filled out completely, leaving it unclear whether the resident had an AD. This oversight was acknowledged by the Social Services Director (SSD) and the Director of Nursing (DON), who both noted the risk of providing services not aligned with the resident's wishes. Resident 17's case involved the absence of a copy of the AD in the medical chart, despite the resident's expressed desire to have one in place. The SSD confirmed that there was no follow-up with the resident's family to establish an AD, and the DON emphasized the importance of having the AD in the chart to guide care decisions. The facility's policy requires that ADs be determined and documented upon admission, which was not followed in this instance. For Resident 28, the ADA form was incomplete, failing to indicate whether the resident had executed an AD. The SSD and DON both recognized that this omission could lead to the resident receiving inappropriate services. The facility's policy mandates that the ADA form be completed upon admission to ensure that residents' treatment preferences are known and respected, which was not done in this case.
Failure to Develop Trauma-Informed Care Plans for Residents with PTSD
Penalty
Summary
The facility failed to develop specific and individualized person-centered care plans for two residents who were trauma survivors, leading to a deficiency in providing trauma-informed care. Resident 17, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and post-traumatic stress disorder (PTSD), did not have a care plan addressing PTSD. Despite having a positive trauma screen and a history of PTSD, the care plans did not include interventions to manage triggers or prevent re-traumatization. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the absence of a care plan for PTSD, which was against the facility's policy. Similarly, Resident 54, who was readmitted with PTSD and spinal stenosis, also lacked a care plan addressing PTSD. The resident was cognitively intact and required assistance with daily activities. Interviews with a Licensed Vocational Nurse and the Director of Nursing revealed that Resident 54 exhibited behaviors such as non-compliance and hoarding, which could be related to PTSD. Despite these observations, there was no specific care plan to manage PTSD symptoms and triggers, which was acknowledged as necessary by the facility's staff. The facility's policy on Trauma Informed Care emphasized the need for care plans that recognize the interrelation between trauma and its symptoms, and the importance of minimizing triggers and re-traumatization. However, the facility did not adhere to this policy for Residents 17 and 54, resulting in a failure to provide the necessary care, treatment, and services for these trauma survivor residents.
Infection Control Deficiencies in PPE Usage and Signage
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies for three residents, leading to potential cross-contamination and infection spread. For Resident 74, who was on Enhanced Barrier Precautions (EBP) due to COVID-19, MRSA, and immunodeficiency, a Certified Nurse Assistant (CNA 5) was observed changing the resident's diaper without wearing the required gown, only wearing gloves. This was acknowledged by CNA 5, who admitted the importance of wearing a gown, mask, and gloves to protect both the resident and themselves. Interviews with other staff, including a Licensed Vocational Nurse (LVN 4) and the Infection Preventionist (IP), confirmed that proper PPE, including gowns and gloves, should be worn during high-contact activities for residents on EBP. Resident 59, diagnosed with ESBL in the urine, was on contact isolation, yet there was no appropriate signage outside the resident's room indicating the transmission-based precautions. The Treatment Nurse (TN) and Infection Prevention Nurse (IPN) confirmed the absence of documentation clearing the resident from contact isolation, emphasizing the need for proper signage to prevent infection spread. The Director of Nursing (DON) also stated that residents on transmission-based precautions should be reassessed and cohorted properly to ensure the safety of other residents. For Resident 10, who was on EBP due to a gastrostomy tube and risk for multidrug-resistant organism infection, a CNA (CNA 4) was observed changing the resident's linen while only wearing gloves, without the required gown. The CNA acknowledged the oversight and the importance of wearing the full PPE during high-contact activities. The Infection Prevention Nurse (IPN) and the Director of Nursing (DON) reiterated the necessity of wearing the required PPE to prevent the spread of infection, as outlined in the facility's policy.
Failure to Obtain Informed Consent for Wander Guard Alarm
Penalty
Summary
The facility failed to implement its policy and procedure regarding informed consent for the use of a wander guard alarm for Resident 59. Resident 59 was admitted with diagnoses including osteoporosis, unsteadiness on feet, and anxiety, and was identified as being at risk for elopement. The Minimum Data Sheet indicated that Resident 59 had severely impaired cognition and required varying levels of assistance with daily activities. During an observation, Resident 59 was seen wearing a wander guard alarm bracelet, but there was no documented evidence that consent was obtained prior to its application. Interviews with Licensed Vocational Nurse 4 and the Director of Nursing confirmed that consent should have been obtained to ensure the resident or their responsible party was informed about the use of the wander guard. The facility's policy on informed consent requires that consent be obtained for medical interventions, including the prolonged use of devices like the wander guard. The failure to obtain informed consent violated Resident 59's rights and placed them at risk for psychological distress due to the discomfort and sound of the alarm.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 89, which had the potential to prevent the resident from receiving necessary care and services. Resident 89 was admitted with diagnoses including dementia, depressive disorder, and unsteadiness on feet, and was assessed to have severely impaired cognition. The resident required supervision or assistance with various activities of daily living and was identified as being at risk for falls. The care plan for Resident 89 included interventions to place the call light within reach and encourage its use for assistance. During an observation, the call light was found hanging on the wall, out of reach, and the resident was unaware of its location. A Certified Nurse Assistant confirmed that the call light should be placed where the resident could see and use it. The Director of Nursing also stated that the call light should be within easy reach to address needs immediately. The facility's policy on call lights, revised in December 2022, indicated that staff should ensure call lights are within reach and secured as needed.
Failure to Complete PASRR for Resident
Penalty
Summary
The facility failed to complete the Level I Pre-Admission Screening and Resident Review (PASRR) for a resident who had been in the facility for more than 30 days. This oversight was identified during a review of the resident's admission record and clinical documentation. The resident, who was readmitted to the facility with diagnoses including malignant neoplasm of the esophagus and bipolar disorder, was found to be severely cognitively impaired and dependent on assistance for personal care. Despite these conditions, the necessary PASRR I evaluation was not conducted upon the resident's readmission, which should have triggered a PASRR II evaluation. Interviews with facility staff revealed a breakdown in the process of coordinating PASRR evaluations. The Admissions Coordinator typically requests PASRR I from the hospital and passes it to the Minimum Data Set Assistant (MDS A), who is responsible for PASRR II. However, in this case, the MDS A acknowledged that a new PASRR I screening should have been completed upon the resident's readmission to determine if a PASRR II was still needed. The facility's policy requires that residents not screened due to certain exceptions must undergo a Level I screening if they remain in the facility for more than 30 days, which was not adhered to in this instance.
Failure to Develop Care Plan for Zoloft Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed Zoloft, a medication used to treat depression. The resident, who had been admitted and readmitted to the facility with diagnoses including major depressive disorder and hypertension, had an active order for Zoloft 50 mg once a day. Despite this, there was no care plan in place to monitor the effectiveness of the medication or to guide staff in implementing specific interventions for the resident. This oversight was confirmed during a review of the resident's medical records and interviews with the Registered Nurse Supervisor and the Director of Nursing, both of whom acknowledged the absence of a care plan. The facility's policy and procedure on comprehensive care plans, revised in December 2022, requires that care plans include measurable objectives and timeframes to meet residents' needs as identified in comprehensive assessments. The lack of a care plan for the use of Zoloft for this resident had the potential to result in inconsistency of care and unnecessary use of psychotropic medication. The deficiency was identified during a survey, highlighting the need for a structured approach to monitor the resident's progress and document alternative interventions as needed.
Failure to Manage Resident's Constipation
Penalty
Summary
The facility failed to manage constipation for a resident over a period of five days, from February 15 to February 19, 2025. The resident, who had been admitted with orthopedic aftercare following surgical amputation and obesity, had moderately impaired cognition and required assistance with daily activities. Despite the resident's complaints of constipation and the known side effect of constipation from taking Norco, the facility did not administer Milk of Magnesia (MOM) until February 19, 2025, and failed to document its effectiveness or follow up with additional treatment when it proved ineffective. Licensed Vocational Nurse 2 (LVN 2) acknowledged the resident's complaints and administered MOM on February 19, 2025, but did not document the outcome or notify the physician when the medication was ineffective. The facility's Medication Administration Record (MAR) showed no bowel movement for the resident since February 14, 2025, and no administration of MOM on the preceding days. The facility's policy required monitoring and reporting adverse reactions to analgesic therapy, but this was not adhered to, resulting in a delay in necessary care and services for the resident.
Failure to Follow Catheter Care Policy
Penalty
Summary
The facility failed to adhere to its policy on foley catheter care for a resident, identified as Resident 50, who had an indwelling catheter. The resident was admitted with diagnoses including benign prostatic hyperplasia and sepsis and was noted to have severely impaired cognitive abilities. During an observation, the resident's catheter port was found to be visibly soiled with a brown substance resembling feces, and there was no securement device in place as required by the care plan and physician's orders. Interviews with facility staff, including the Infection Prevention Nurse, a Licensed Vocational Nurse, and the Director of Nursing, confirmed that the soiled catheter and lack of a securement device were not in compliance with the facility's policies. The staff acknowledged that these oversights could increase the risk of infection and injury to the resident. The facility's policy on catheter care, revised in December 2022, mandates appropriate care and maintenance of dignity and privacy for residents with indwelling catheters.
Improper Management of Tube Feeding for Resident
Penalty
Summary
The facility failed to ensure proper management of tube feeding for a resident, identified as Resident 16, who was receiving nutrition through a gastrostomy tube. During an observation, it was noted that the tube feeding was running while the resident was being changed in a supine position, which is against the care plan that requires the head of the bed to be elevated at least 30-45 degrees during and after feeding to prevent aspiration. The Licensed Vocational Nurse (LVN) acknowledged that the tube feeding should have been paused during the resident's change to prevent choking or aspiration. Resident 16 had a medical history that included cerebral palsy, paraplegia, and aphasia, and was assessed as completely immobile and unable to make decisions. The resident's care plan indicated a high risk for complications such as aspiration, and the facility's policy required the head of the bed to be elevated during feedings. Despite this, the tube feeding was not paused during the resident's care, as confirmed by both the LVN and a Certified Nurse Assistant (CNA), who stated that the feeding sometimes resumed before the resident's care was completed. The Director of Nursing also confirmed that the tube feeding should be turned off during such procedures to prevent serious complications.
Failure to Ensure Physician Signatures on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations for a resident were signed and dated by the attending physician, which is a requirement for maintaining proper medical care and continuity. Specifically, the Skilled Nursing Pharmacy Recommendations (SNPR) for September 2024 and December 2024 for Resident 22 were not appropriately signed and dated by the attending physician. The Medical Record Director (MRD) noted that the September 2024 SNPR was undated, and the December 2024 SNPR lacked both a signature and a date. The MRD also mentioned that the physician likely visited in January 2025, but there was no record of this visit, and the last physician note was from December 28, 2024. Resident 22, who was readmitted to the facility with diagnoses including gastrostomy and diabetes mellitus, was noted to have severely impaired cognition and used a wheelchair for mobility. The Director of Nursing (DON) confirmed that during physician visits, the physician should sign the pharmacy recommendations, emphasizing the importance of a signed SNPR for indicating the physician's evaluation and acknowledgment. The facility's policy requires that the medical care of each resident be under the supervision of a licensed physician, with orders and progress notes maintained according to OBRA regulations and facility policy.
Inadequate Posting of Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent place readily accessible to residents and visitors. Observations on multiple dates revealed that the Nurse Staffing Sheet, which contains the facility's current resident census and total number and actual hours worked by licensed and unlicensed nursing staff, was only posted at the reception desk near the entrance across from Nursing Station A. This made the information inaccessible to residents and visitors on the opposite side of the facility by Nursing Station B. Interviews with the Director of Staff Development confirmed that the staffing information was only posted in the reception area and acknowledged that it should also be posted at Nursing Station B to ensure accessibility. The facility's policy and procedure indicated that staffing information should be posted in a prominent place readily accessible to residents and visitors, which was not adhered to in this instance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure informed consent was obtained for the administration of Trazodone 50 mg every night for insomnia in one of the sampled residents. Resident 31, who was admitted with chronic pain syndrome and low back pain, had intact cognitive abilities and the capacity to understand and make decisions. Despite this, the Physician Document of Informed Consent (PDIC) form for Trazodone was not signed by the resident, indicating that the risks and benefits of the medication were not discussed with them. During interviews, both the Registered Nurse Supervisor and the Director of Nursing confirmed that the PDIC form was not signed, which meant that the resident was not informed about the medication's risks, benefits, or alternative treatments. The facility's policy requires that residents be educated on these aspects before administering psychotropic drugs, but this was not adhered to in the case of Resident 31.
Resident Abuse by Family Member During Visitation
Penalty
Summary
The facility failed to protect a resident from physical abuse during a visitation by a family member. The resident, who had diagnoses of dementia and bipolar disorder, was on 1:1 monitoring due to agitation and aggressiveness. However, the staff left the resident alone with the family member, who subsequently hit the resident, resulting in discoloration of the resident's right lower lip and left temporal area. The incident was reported after the resident yelled for a nurse, and the family member admitted to hitting the resident due to verbal aggression. The resident's progress notes indicated that the resident was given Tylenol for pain and was transferred to a general acute care hospital for further assessment. Interviews with staff and the resident's roommate confirmed the sequence of events leading to the abuse. The facility's policy on abuse, neglect, and exploitation defines abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish, which was not adhered to in this case.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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