Southern California Hosp At Culver City D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Culver City, California.
- Location
- 3828 Delmas Terrace, Culver City, California 90232
- CMS Provider Number
- 555874
- Inspections on file
- 25
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Southern California Hosp At Culver City D/p Snf during CMS and state inspections, most recent first.
A resident with chronic respiratory failure post-tracheostomy, anoxic brain injury, and chronic heart failure, and who was totally dependent for ADLs, was found by nursing staff to have unexplained redness and later a mild contusion on the forehead. Nursing notified the NP and the family and documented that VS were within normal limits and the resident showed no signs of pain or distress, but the cause of the bruise was unknown. Social services did not follow up with APS and the LTC Ombudsman until two days after the injury, and CDPH was not notified until four days after the incident, despite facility policy and state law requiring notification of the state licensing agency within 24 hours and immediate phone notification to the LTC Ombudsman when potential abuse indicators such as bruises or discoloration are identified.
A resident with acute respiratory failure did not receive a stat EEG as ordered when the EEG technician was verbally instructed by the house neurologist, who was not the ordering provider, to delay the test. The verbal hold was not documented, and the technician did not consult the ordering provider or notify nursing staff, resulting in a delay of the procedure.
The facility did not submit its PBJ Staffing Data Report for Q4 FY 2024 to CMS. The ADM stated that the CNM was responsible for the submission, which was not done on time. The facility lacked a validation report and a policy for the PBJ report. CMS policy mandates electronic submission of staffing data by a specified deadline.
Two residents did not receive scheduled showers due to a broken shower hose, resulting in only bed baths being provided. One resident was observed to be poorly groomed, and another expressed frustration over not feeling fully clean. Additionally, a CNA stood while feeding a resident, contrary to protocol, which could impact the resident's self-esteem. The facility's policies on bathing and dignity were not followed.
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) appeal process form to three residents, which is required when their Medicare-covered services are ending. This deficiency was identified during an interview with the Director of Quality and Risk Management, who acknowledged that the NOMNC forms were missing. The absence of these forms could prevent residents from exercising their right to file an appeal, potentially leading to violations of residents' rights or unwanted discharges.
The facility failed to ensure annual competencies were signed and dated by three employees, potentially leading to inadequate care. A review of employee files revealed missing signatures and dates on competencies for two LVNs. The Director of Quality and Risk Management acknowledged the risk of incomplete competencies, which could result in inadequate care.
The facility failed to maintain proper food storage and temperature monitoring practices. A walk-in refrigerator lacked a thermometer, risking food spoilage, while the reach-in freezer contained unlabeled and undated food items, potentially leading to expired food. The Sous Chef acknowledged these issues, which contravened the facility's policies requiring labeling and temperature monitoring.
A facility failed to cover a resident's indwelling catheter with a privacy bag, compromising the resident's dignity. The resident, who had multiple health issues and required assistance with daily activities, was observed without the catheter cover, contrary to facility policies. An RN acknowledged the importance of the cover for maintaining the resident's modesty.
The facility did not post survey results and complaint investigation reports in a location accessible to residents and the public, as required by CDPH regulations. The DQRM acknowledged that these documents were kept in her office instead of being available at the nursing station hallway. The CNM confirmed the importance of making these documents accessible to demonstrate compliance and quality of care. This deficiency was noted during a survey.
A facility failed to resubmit the PASARR Level I screening for a resident with anxiety, depression, and psychosis, as indicated by the MDS. The initial screening incorrectly stated no serious mental illness, closing the case without a Level II evaluation. Staff interviews revealed reliance on the transferring facility for initial screening and acknowledged the need for resubmission based on updated assessments.
A facility failed to label and date the ventilator tubing for a resident, which is crucial for preventing respiratory infections. The oversight was confirmed by a respiratory therapist who admitted to changing the tubing without dating it. A registered nurse also acknowledged the importance of dating the tubing, as it is changed daily or as scheduled. The facility's policy on mechanical ventilation did not specify the need to date and label the tubing, contributing to the deficiency.
A resident with a history of acute respiratory failure and on gastrostomy tube feeding was observed with the head of the bed elevated at only 10 degrees, contrary to the care plan requiring 45 degrees to prevent aspiration. A nurse confirmed the risk of aspiration due to the improper elevation.
A resident receiving IV antibiotic treatment for sepsis had unlabeled and undated IV tubing, contrary to the facility's policy requiring tubing to be changed every three days and labeled. The inconsistency in practice was noted by a nurse, and the clinical nurse manager confirmed the labeling responsibility of the nursing staff.
A facility failed to remove expired medication from its storage, risking potential medication errors. During an inspection, Vancomycin prescribed for a resident with respiratory failure was found expired in the medication storage refrigerator. Staff acknowledged the oversight and the risk it posed, noting that expired medications should be returned to the pharmacy as per protocol.
A resident with thyroid cancer and other conditions did not receive a required TSH level test as ordered by a physician. The test was not conducted in November, which was confirmed by a nurse and pharmacist, potentially affecting the resident's medication management. Facility policy mandates that lab tests requested by physicians be provided, but this was not adhered to in this case.
A resident with multiple health conditions, including dysphagia, did not receive necessary dental services despite expressing a desire for dental care. Interviews with staff confirmed the absence of a dental contract and the lack of adherence to the facility's policy requiring oral assessments and arrangements for dental services.
The facility did not hold Quality Assurance Performance Improvement (QAPI) meetings quarterly as required. The last meeting was in December 2024, with the previous one in May 2024, missing the August 2024 meeting. This failure could lead to systemic issues, as confirmed by the Director of Quality and Risk Management (DQRM). The facility's policy requires quarterly meetings and monthly subcommittee meetings, which were not adhered to.
A facility failed to label and date ventilator tubing for a resident, as observed during a survey. The respiratory therapist admitted to changing the tubing without dating it, which is crucial for preventing infections. The facility's policy did not specify the need for dating the tubing, leading to a risk of respiratory infections.
The facility failed to meet nursing professional standards for two residents. One resident's elevated heart rate was not documented or addressed for over three hours, despite facility procedures requiring reassessment and documentation. Another resident did not have documented range of motion services on two scheduled days, risking contractures. These deficiencies highlight lapses in adhering to the facility's documentation policies.
A facility failed to prevent neglect and investigate alleged violations involving three residents. An LVN tied a sheet to a broken bedrail, leading to a resident's fall, ignored a wound vac alarm, leaving another resident in the dark, and failed to report critical test results for a third resident. The facility lacked investigation reports and corrective actions for these incidents.
A resident with severe cognitive and physical impairments fell from bed due to a broken bedrail that was inadequately secured with a sheet. The night shift nurse did not report the issue, and a replacement bed was not ordered, leading to the resident's unwitnessed fall. The facility's policies on equipment failure and fall prevention were not followed, resulting in a deficiency.
A facility failed to ensure an LVN in the subacute unit had a current BLS certification, as required by the job description. This deficiency was identified during a review of care for a resident with chronic respiratory failure and a preference for resuscitation/CPR. The LVN's BLS certification had been expired for over nine months, potentially delaying emergency care for the resident and others in the unit.
The facility failed to maintain room temperatures within the acceptable range of 71 to 81 degrees Fahrenheit for 17 residents in the Sub-Acute Unit. Temperatures were recorded as high as 89.7 degrees, and spot coolers were ineffective in reducing the heat. Residents and staff reported discomfort, and the facility's HVAC system was insufficient to manage the temperature, leading to an Immediate Jeopardy situation.
Failure to Timely Report Injury of Unknown Origin to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin for one resident to CDPH, APS, and the LTC Ombudsman within 24 hours, as required by state law and the facility’s abuse policy. The resident had been readmitted in March 2026 with chronic respiratory failure post-tracheostomy, anoxic brain injury, and chronic heart failure. An MDS assessment from January 2026 documented that the resident had severely impaired cognitive skills for daily decision-making and was dependent on staff for all activities of daily living and transfers. On 3/22/2026 at 5:49 p.m., the resident’s primary nurse notified the charge nurse that redness was noted on the resident’s forehead. The resident’s wife and daughter were at the bedside and were informed of the redness. The NP was notified to assess the resident, vital signs were within normal limits, and the resident appeared comfortable with no signs or symptoms of pain or distress. Later that evening at 8:30 p.m., nursing documentation indicated that the resident’s wife was notified that the NP had assessed the forehead discoloration as a mild contusion, with a plan to monitor and administer pain medication as needed. The cause of the bruise was unknown, meeting the definition of an injury of unknown origin. On 3/24/2026 at 10:49 a.m., a social services note documented that the SW consulted with Risk Management and the Social Services Manager regarding the need to report the bruise of unknown cause on the resident’s forehead. The SW attempted to contact the LTC Ombudsman that day, leaving a voicemail, and completed and faxed the SOC341 form to APS on the same date, which was two days after the incident. The facility’s incident report, dated 3/26/2026, showed the incident occurred on 3/22/2026 at 1:10 p.m. and that CDPH was notified on 3/26/2026, four days after the incident. During interviews, the DRQ and SW confirmed these timelines and acknowledged that reporting occurred more than 24 hours after the incident, contrary to state law and the facility’s abuse policy, which requires notification of the state licensing agency within 24 hours and immediate phone notification to the LTC Ombudsman when indicators such as bruises or discoloration are present.
Delay in Stat EEG Due to Unverified Verbal Hold Order
Penalty
Summary
A deficiency occurred when a stat (immediate) EEG order for a resident was not completed as directed by the physician. The resident, who had been admitted with acute respiratory failure, had a stat EEG ordered by a covering physician. The EEG was a contracted service to be performed by an outside technician. Although the technician arrived to perform the test, the house neurologist verbally instructed the technician to hold off on conducting the EEG, despite not being the ordering provider and without a written order to do so. The EEG was subsequently delayed until the following day. Facility policy indicated that non-emergent verbal orders should not be accepted, and emergent verbal orders must be signed by the physician prior to leaving the nursing unit. In this case, the verbal instruction to hold the EEG was not documented as a formal order, and the technician did not consult the ordering provider or inform the assigned nurse about the hold. This sequence of actions and inactions resulted in the stat EEG not being performed as ordered.
Failure to Submit PBJ Staffing Data Report
Penalty
Summary
The facility failed to submit its Payroll-Based Journal Staffing Data Report (PBJ) for Quarter 4 of the Fiscal Year 2024 to the Center of Medicare/Medicaid Services (CMS). This deficiency was identified during a record review on December 12, 2024, which revealed that the staffing data for the specified period had not been submitted. During an interview on December 15, 2024, the Administrator (ADM) acknowledged that the Clinical Nurse Manager (CNM) was responsible for submitting the staffing data but had not done so in a timely manner. The ADM also admitted that the facility could not provide a validation report to prove data submission and lacked a policy regarding the PBJ Staffing Data Report. The CMS policy requires facilities to electronically submit direct care staffing information based on payroll and other auditable data, with a deadline for the reporting period of July 1st to September 30th, 2024, being November 14th, 2024.
Failure to Provide Scheduled Showers and Maintain Dignity During Feeding
Penalty
Summary
The facility failed to ensure that two out of six sampled residents received their scheduled showers twice a week. Resident 5, who was admitted with diagnoses including respiratory failure and anoxic encephalopathy, was observed to be poorly groomed, with dirt around the ears and arms. The responsible party for Resident 5 reported that the resident had not appeared clean since admission, despite staff claims that the resident was being bathed in bed. Similarly, Resident 8, who had diagnoses including respiratory distress and thyroid cancer, reported not having received a shower in weeks due to a broken shower hose, resulting in only bed baths being provided. This lack of proper bathing was confirmed by a review of the Sub-Acute Shower Log, which showed that neither resident received showers from late November to mid-December. Additionally, the facility failed to maintain dignity during meal assistance for Resident 8. During a dining observation, a CNA was seen standing while feeding Resident 8, rather than sitting at eye level as per protocol. The CNA acknowledged that standing while feeding could negatively impact the resident's self-esteem. The Clinical Nurse Manager confirmed that the protocol required staff to sit at eye level to avoid creating a power imbalance and to prevent residents from feeling intimidated. The facility's policies and procedures, including those for bathing and resident rights, were not adhered to, as evidenced by the lack of regular showers and the improper feeding posture. The facility's policy stated that residents should receive showers or tub baths at least twice weekly and be treated with dignity and respect. The failure to provide these basic care services and maintain dignity during feeding compromised the residents' rights to a dignified existence and proper hygiene.
Failure to Provide NOMNC Forms to Residents
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) appeal process form to three residents, which is required when their Medicare-covered services are ending. This deficiency was identified during an interview with the Director of Quality and Risk Management (DQRM), who acknowledged that the NOMNC forms were missing for the residents in question. The DQRM explained that the absence of these forms could prevent residents and their responsible parties from exercising their right to file an appeal, potentially leading to violations of residents' rights or unwanted discharges. The facility's policy and procedures, titled Medicare Beneficiary Discharge Dispute Process, require informing Medicare patients of their rights to dispute a discharge through the Important Message from Medicare (IMM) form. However, the failure to provide the NOMNC forms as part of this process was noted as a deficiency, impacting the residents' ability to make informed decisions regarding their Medicare coverage and potential liabilities.
Incomplete Employee Competencies
Penalty
Summary
The facility failed to ensure that annual competencies were signed and dated by three employees, which could potentially lead to incompetent and inadequate care for all residents. During a record review of five randomly selected employee files, it was found that a Licensed Vocational Nurse (LVN 1) had missing employee and preceptor signatures on their Restraints, Skills Fair, and Critical Clinical Alarm competencies. Additionally, another Licensed Vocational Nurse (LVN 2) had missing dates and no facilitator's name or signature on their General Hiring Orientation form and Care of the Post-Op Bariatric Surgery Patient In-service quiz. Furthermore, LVN 2's Nursing Intravenous (IV) Medication Mixing Skills Checklist was incomplete, with no date and the facilitator's name struck out. During a concurrent interview and record review with the Director of Quality and Risk Management (DQRM), it was stated that all staff competencies and skill fairs should be completed upon hire and annually with the facility's education department and unit. The DQRM acknowledged that all competencies should have been signed by the employees, facilitators, and dated once completed. The DQRM also noted that the risk of incomplete employee competencies could result in inadequate care and uncertainty about whether the competency was truly authenticated with what was taught and learned. The facility's policy and procedures indicated that the Sub Acute Unit should have sufficient nursing to provide services to maintain the highest practical well-being of each patient, as determined by patient assessments and individual care plans.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to ensure proper temperature monitoring and labeling of food items in the kitchen, which could potentially lead to food spoilage and expiration. During an observation and interview with the Sous Chef, it was noted that the walk-in refrigerator, which stored vegetables and fruits, lacked a thermometer. The Sous Chef acknowledged that a thermometer was necessary to monitor the temperature and prevent food spoilage, and speculated that it might have been removed by someone. Additionally, during an inspection of the reach-in freezer, it was observed that there were opened and unlabeled Ziplock bags containing Uncrustables peanut butter and jelly sandwiches, as well as unlabeled and undated pureed rice and breakfast kosher meals. The Sous Chef admitted that the absence of labels and dates on frozen foods could result in uncertainty about their expiration status. The facility's policy and procedures require that unused portions and open packages be covered, labeled, and dated, and that each refrigerator storage unit have an independent thermometer.
Failure to Maintain Resident Dignity by Not Covering Catheter
Penalty
Summary
The facility failed to ensure that a resident's indwelling catheter was covered with a privacy bag, which is a practice intended to protect the resident's modesty and dignity. This deficiency was observed during an inspection involving Resident 8, who was admitted to the facility with diagnoses including respiratory distress, thyroid cancer, and neurogenic bladder. The resident's Minimum Data Set (MDS) indicated that they were cognitively able to understand and required assistance with range of motion, toileting hygiene, showering, and dressing. Despite these needs, the facility did not adhere to its policy of covering the indwelling catheter, potentially leading to feelings of humiliation for the resident. During an interview, a registered nurse (RN) confirmed that the indwelling catheter should have been covered with a privacy bag to maintain the resident's dignity, likening the cover to a piece of clothing that would improve the resident's appearance. The facility's policies on resident rights and guidelines emphasize the importance of treating residents with kindness, dignity, and respect, and providing necessary care to maintain their highest practicable wellbeing. However, the failure to cover the catheter was a deviation from these policies, as it did not align with the facility's commitment to ensuring residents' comfort and dignity.
Failure to Post Survey Results and Complaint Reports
Penalty
Summary
The facility failed to ensure that survey results and complaint investigation reports from the previous three years were posted in a location readily accessible to residents and the public. During an observation and interview, the Director of Quality and Risk Management (DQRM) admitted that these documents were kept in a separate binder in her office and were not available at the nursing station hallway as required. This practice was contrary to the facility's policy and the California Department of Public Health (CDPH) regulations, which mandate that such information be accessible to residents, visitors, and family members. The Clinical Nurse Manager (CNM) confirmed that the survey results and complaint investigation reports should be easily accessible to ensure transparency about the facility's compliance and quality of care. The facility's Resident Orientation Packet and the California Standard Admission Agreement for Skilled Nursing Facilities both emphasize the residents' right to examine survey results and plans of correction. However, the facility did not adhere to these guidelines, resulting in a deficiency noted by the surveyors.
Failure to Resubmit PASARR Level I Screening for Resident with Psychiatric Disorders
Penalty
Summary
The facility failed to complete and re-submit the Preadmission Screening and Resident Review (PASARR) Level I screening for a resident with diagnoses of anxiety disorder, depression, and psychosis. This oversight was identified during a review of the resident's Minimum Data Set (MDS), which indicated active psychiatric disorders. The initial PASARR Level I screening, completed by the facility, incorrectly stated that the resident had no serious mental illness diagnosis and was not receiving psychotropic medications, leading to the case being closed without a Level II mental health evaluation. Interviews with facility staff revealed that the Clinical Nurse Manager relied on the transferring facility to complete the Level I screening before transfer, and the Registered Nurse responsible for PASARR acknowledged the need to resubmit a new Level I screening based on the updated MDS assessment. The PASRR reference manual requires facilities to notify the state authority of significant changes in a resident's mental condition, which was not done in this case, potentially impacting the resident's access to appropriate psychiatric care.
Failure to Date Ventilator Tubing
Penalty
Summary
The facility failed to ensure that the ventilator tubing for one resident was labeled and dated, which is a critical step in preventing respiratory infections. During an observation, it was noted that the ventilator tubing connected to the resident's tracheostomy was not dated. This oversight was confirmed during an interview with a respiratory therapist who admitted to changing the tubing but neglecting to date it. The therapist acknowledged the importance of dating the tubing to monitor how long it has been in use, which is essential to prevent bacterial growth and subsequent respiratory infections. Further interviews with a registered nurse corroborated the requirement for the respiratory tubing to be dated, as it is changed daily or as scheduled by the respiratory therapist. The facility's policy and procedure on mechanical ventilation, dated December 2023, highlighted the risk of infection as a common hazard associated with mechanical ventilation. However, the policy did not explicitly state the need to date and label the ventilator tubing, which contributed to the deficiency observed.
Improper Bed Elevation for Resident on Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving tube feeding was provided care in accordance with professional standards of practice. Specifically, the head of the bed for a resident on gastrostomy tube feeding was not elevated to the required 30 to 45 degrees, as observed during a survey. Instead, the head of the bed was elevated at approximately 10 degrees while the resident was receiving continuous tube feeding. This practice was contrary to the resident's care plan, which specified that the head of the bed should be elevated at 45 degrees to prevent aspiration. The resident involved had a history of acute respiratory failure and was receiving tube feeding due to dysphagia and respiratory failure. The facility's policy on gastric tube feeding, dated September 2022, indicated that patients fed by gastric tubes should receive appropriate treatment to prevent aspiration and other complications. During an interview, a registered nurse confirmed that the head of the bed should be elevated at least 30 to 45 degrees for residents receiving continuous tube feeding to prevent aspiration, acknowledging that the resident was at risk due to the improper bed elevation.
Failure to Label and Date IV Tubing
Penalty
Summary
The facility failed to ensure that intravenous (IV) tubing was labeled and dated for a resident receiving IV antibiotic treatment. This deficiency was observed in the case of a resident who was admitted with diagnoses including tracheostomy and anemia and was in a comatose state. The resident had an active order for Zosyn, an antibiotic, to be administered intravenously every eight hours for the treatment of sepsis. During an observation, it was noted that the IV tubing connected to the medication was unlabeled and undated, and the registered nurse present was unable to determine when the tubing was last changed. The facility's policy and procedure for intravenous therapy indicated that IV tubing should be changed every three days and labeled with the date of change. However, the registered nurse stated that the tubing should be changed twice a week, on Thursdays and Sundays, which was inconsistent with the facility's policy. The clinical nurse manager confirmed that it was the responsibility of the licensed nursing staff to label the IV tubing with the date it was changed, as part of the standard practice to track when it needs to be replaced. The failure to label and date the IV tubing had the potential to place the resident at risk for infection and IV therapy complications.
Expired Medication Found in Storage
Penalty
Summary
The facility failed to ensure that expired medication was not kept in the medication storage refrigerator, which could potentially lead to administering expired medication. During an observation of the facility's medication storage room refrigerator, a medication prescribed for a resident with a diagnosis of respiratory failure was found to be expired. The medication, Vancomycin, was labeled with an expiration date and time that had already passed. During an interview, a registered nurse acknowledged that the expired medication should have been returned to the pharmacy and recognized the risk of storing expired medication, which could result in a medication error. The clinical nurse manager also confirmed that the protocol for expired medication was to contact the pharmacy for replacement. The facility's policy indicated that expired medications should be removed and stored separately from those available for administration.
Failure to Complete Ordered Laboratory Test for Resident
Penalty
Summary
The facility failed to ensure that a laboratory test was completed for one of the sampled residents, identified as Resident 8. The resident was admitted with diagnoses including respiratory distress, thyroid cancer, and neurogenic bladder, and was dependent on staff for various activities of daily living. A physician order dated 11/4/2024 required a thyroid stimulating hormone (TSH) level test to be conducted, but this test was not completed for the month of November. This oversight was confirmed during an interview with a registered nurse, who acknowledged that the absence of the TSH test could place the resident at risk for not receiving the correct dose of thyroid medication. Further interviews with the facility's pharmacist corroborated the failure to conduct the TSH test as ordered. The pharmacist emphasized the importance of monitoring TSH levels to ensure the resident's thyroid levels remain within a normal range, as deviations could exacerbate the resident's thyroid condition. The facility's policy indicated that lab tests requested by physicians should be provided to residents, but this protocol was not followed in this instance, leading to the deficiency.
Failure to Provide Dental Services to Resident
Penalty
Summary
The facility failed to provide dental services to one of the six sampled residents, identified as Resident 13. Resident 13 was admitted with a diagnosis of dysphagia and had additional medical conditions including peripheral vascular disease, chronic renal failure, and congestive heart failure. Despite being independent in oral hygiene, Resident 13 expressed discontent about not receiving dental services and desired to have his teeth cleaned. Interviews with the resident and staff, including a social service worker and a registered nurse, confirmed that no dental services were provided, and there was no dental contract in place for the unit. The facility's policy and procedure on dental services, dated July 2022, required an oral assessment upon admission and arrangements for necessary dental services. However, the policy was not followed, as evidenced by the lack of dental care for Resident 13. The social service worker and registered nurse acknowledged the importance of dental care to prevent oral health issues, yet no actions were taken to ensure Resident 13 received the necessary services. The deficiency was identified through interviews and record reviews, highlighting a failure to adhere to the facility's established procedures for dental care.
Failure to Hold Quarterly QAPI Meetings
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) meetings were held quarterly as required. During an interview and record review with the Director of Quality and Risk Management (DQRM), it was revealed that the last QAPI meeting was conducted in December 2024, with the previous meeting held in May 2024. The DQRM acknowledged that a meeting should have been held in August 2024, but it did not occur. This lapse in holding quarterly meetings was identified as having the potential to result in systemic issues within the facility. The facility's policy, titled Quality Council/Leadership Committee, dated July 2022, mandates that the committee meet at least quarterly. Additionally, a subcommittee, including the Program Director, Medical Director, and Director of Nursing, along with any appropriate staff, is required to meet monthly. The failure to adhere to this schedule was confirmed by the DQRM, who noted the risk of systemic issues arising from not meeting the quarterly requirement.
Failure to Date Ventilator Tubing
Penalty
Summary
The facility failed to ensure that the ventilator tubing for one of the sampled residents was labeled and dated. During an observation, it was noted that the ventilator tubing connected to the resident's tracheostomy was not dated. This oversight was confirmed during an interview with a respiratory therapist who admitted to changing the tubing but not labeling it with the date. The therapist acknowledged the importance of dating the tubing to monitor how long it has been in use, which is crucial for preventing bacterial growth and respiratory infections. Further interviews with a registered nurse corroborated the requirement for the tubing to be dated, as it is typically changed daily or as scheduled by the respiratory therapist. The facility's policy on mechanical ventilation, while addressing infection control practices, did not specifically mandate the dating and labeling of ventilator tubing. This omission in the policy and the failure to date the tubing placed the resident at risk for respiratory infections.
Deficiencies in Documentation and Care Standards
Penalty
Summary
The facility failed to ensure nursing professional standards were met for two residents. For the first resident, there was no documentation of an assessment in the electronic health record (EHR) when the resident's heart rate was elevated at 106 beats per minute, which is above the normal range. This elevated heart rate was not addressed for over three hours, from 8:19 p.m. to 11:38 p.m. The resident, who was bed-bound with a tracheostomy and a G-tube, had a care plan that required monitoring for physical or nonverbal indicators of discomfort or distress. Interviews with registered nurses revealed that the facility's procedure for abnormal vital signs was to reassess and document the vital signs, administer any necessary PRN orders, and notify the attending physician if needed. However, the documentation was missing during the specified time frame. For the second resident, the facility failed to document the provision of range of motion (ROM) services on two specific dates. The resident, who was in a persistent vegetative state with chronic respiratory failure and flaccid quadriplegia, had a care plan that included maintaining muscle strength and preventing contractures through ROM exercises. The EHR indicated that passive ROM was scheduled to be provided weekly on specific days, but the records for two of these days were blank, indicating a lack of documentation for the services rendered. An interview with the Assistant Chief Nursing Officer confirmed the absence of documentation for the ROM services on the specified dates. The facility's policy and procedure on documentation, revised in September 2022, stated that continuous reassessment and documentation of patient care activities are expected. However, the lack of documentation for both residents' care activities indicates a failure to adhere to these standards, resulting in deficiencies in the care provided to the residents.
Neglect and Investigation Failures in LTC Facility
Penalty
Summary
The facility failed to prevent potential neglect and thoroughly investigate alleged violations involving three residents. In the first case, a Licensed Vocational Nurse (LVN) tied a sheet to a resident's bed frame and broken bedrail, which resulted in the resident falling out of bed. The resident, who was nonverbal and quadriplegic, required assistance with all activities of daily living. Despite the incident, the LVN continued to be assigned to the resident's care without any corrective action being taken. In the second case, the same LVN refused to assess another resident's wound vacuum when it was alarming, instead shutting the door and turning off the light, leaving the resident in the dark without assistance. The resident, who had a chronic lower extremity ulcer and a recent hip debridement, expressed feeling unsafe in the care of the LVN. The facility's former manager confirmed that the LVN did not follow standard nursing care procedures to assess the wound or seek assistance from more knowledgeable staff. In the third case, the LVN failed to report a resident's KUB test results to the physician, which indicated a possible ileus or obstruction. The resident had a history of chronic encephalopathy and dysphagia. The failure to report the results delayed the physician's awareness and potential treatment. The facility was unable to provide investigation reports or corrective actions for these incidents, despite having a policy in place for mandatory reporting and investigation of abuse and neglect.
Failure to Address Broken Bedrail Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding medical equipment failure and supervision, resulting in a deficiency. A resident with a complex medical history, including chronic respiratory failure, quadriplegia, and severe cognitive impairment, was involved in an incident where a broken bedrail was inadequately secured with a sheet by a night shift nurse. This makeshift solution was not reported to the house supervisor, and a replacement bed was not ordered, leaving the resident at risk. The resident, who required assistance with all activities of daily living and was nonverbal, fell from the bed due to the broken bedrail. The incident was unwitnessed, and the resident was found on the floor by a respiratory therapist. The day shift nurse, upon discovering the situation, requested a new bed, but the fall had already occurred. The facility's Director of Risk Management confirmed that the root cause analysis identified the failure to report the broken bedrail and the inadequate temporary fix as the primary issues. The facility's policies on medical equipment failure and fall prevention were not followed. The policy required immediate removal and securing of malfunctioning equipment and appropriate clinical intervention, which did not occur. Additionally, the fall prevention program outlined strategies to minimize fall risks, such as ensuring bedrails are functional and beds are in the lowest position, which were not adequately implemented in this case.
Expired BLS Certification for LVN in Subacute Unit
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) assigned to the subacute unit had a current Basic Life Support (BLS) certification, as required by the facility's job description. This deficiency was identified during a review of the care provided to a resident with a history of chronic respiratory failure, recent tracheostomy, cardiac arrest, and anoxic encephalopathy. The resident's Practitioner Orders for Life Sustaining Treatment (POLST) indicated a preference for resuscitation/CPR in life-threatening situations. Despite this, LVN 1, who was responsible for the resident's care on multiple occasions, had an expired BLS certification for over nine months. The issue was discovered during an interview and record review with the Operational Manager of Human Resources, who acknowledged that a report had been sent to the unit manager regarding the expired certification. However, the Manager of the Subacute unit admitted that the expiration was overlooked due to a flaw in the process where employees upload their certificates, but Human Resources does not always see them. This oversight had the potential to delay emergency care for the resident and other residents in the subacute unit who required full treatment in life-threatening situations.
Failure to Maintain Safe Room Temperatures in Sub-Acute Unit
Penalty
Summary
The facility failed to maintain acceptable room temperatures ranging from 71 to 81 degrees Fahrenheit for 17 residents in the Sub-Acute Unit. This deficiency was observed during a survey conducted on September 9, 2024, where temperatures in the residents' rooms and common areas were recorded as being above the acceptable range, with some rooms reaching as high as 89.7 degrees Fahrenheit. The issue was first noticed on September 8, 2024, by an engineer who reported the temperatures were out of range and requested an increase in the chiller's capacity. Interviews with staff and residents revealed that the facility's HVAC system was running at full capacity, yet it was insufficient to maintain the required temperature range. Spot coolers were brought in to assist with cooling, but residents reported that these measures were ineffective in bringing the temperature down. Residents expressed discomfort due to the heat, and staff members, including a Licensed Vocational Nurse, also noted the high temperatures and took personal measures to cope with the heat, such as using portable fans. The facility's policies and procedures indicated that the sub-acute unit should provide a safe and comfortable environment, with specific temperature ranges outlined. However, the facility was unable to adhere to these guidelines, resulting in an Immediate Jeopardy situation being called by the Department. The facility's failure to maintain a safe and comfortable environment for its residents was a significant deficiency, as it placed residents at risk for heat-related health issues.
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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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