Studebaker Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, California.
- Location
- 13226 Studebaker Rd, Norwalk, California 90650
- CMS Provider Number
- 056425
- Inspections on file
- 55
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 46
Citation history
Health deficiencies cited at Studebaker Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of falls, subarachnoid hemorrhage, muscle weakness, failure to thrive, and progressively worsening cognition was assessed as a high fall risk and totally dependent for ADLs, yet the care plan only directed staff to keep the call light within reach and encourage its use, without addressing the resident’s disorientation or inability to communicate needs or use the call light. After two unwitnessed falls in which the resident was found on the floor, unable to describe the events due to confusion, fall reports repeatedly identified confusion, gait imbalance, incontinence, and recent admission as predisposing factors. Although the IDT later identified the resident’s diagnoses, cognitive and functional limitations, unfamiliar environment, and impaired safety awareness as contributing factors and discussed specific interventions such as a low bed, floor pads, a tab alarm, and grab bars, these interventions were not incorporated into the care plan, and nursing leadership acknowledged that the resident’s confusion and need for increased monitoring and targeted fall-prevention measures were not timely care planned.
A resident with severe cognitive impairment, significant neurologic diagnoses, and total dependence for ADLs was newly admitted, but the attending physician did not complete or document an initial H&P or any progress notes following admission. Medical record review confirmed there was no evidence the physician had evaluated the resident, even though the physician was in the facility seeing other residents. The MR staff reported that the physician was notified of the admission but no follow-up reminder was made, and the physician acknowledged not following the facility’s physician services policy, which required an evaluation and written physical exam within a defined timeframe after admission.
A resident with severe cognitive impairment, significant neurologic diagnoses, and a care plan requiring maximal assistance with ADLs and repositioning had no ADL documentation recorded on the task sheet for one evening shift. The CNA assigned to that shift later reported providing oral care, incontinence care, and repositioning but acknowledged forgetting to document these services, resulting in a gap in the medical record. Review by the DSD and statements from the DON confirmed that this lack of documentation was inconsistent with facility policies requiring clear, accurate ADL and medical record documentation for each shift.
A resident with a history of stroke and PTSD, who was cognitively intact and required maximal assistance with ADLs, reported concern after a CNA cursed in the resident’s presence while providing care. The CNA acknowledged spilling water in the room and using foul language, and the DON confirmed the resident stated she did not appreciate the outburst. Facility policies stated residents have the right to be free from abuse and defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing.
A cognitively intact resident with ALS and major depressive disorder, dependent for ADLs, reported that a CNA made a sexually inappropriate pelvic thrusting gesture on a stool in the resident’s room, which the resident perceived as mocking his sexual orientation and which made him angry. The resident informed the DSD, a mandated reporter, of the incident, but the DSD did not report the allegation to CDPH or other required authorities. The DON later acknowledged that the allegation constituted abuse and should have been reported immediately in accordance with the facility’s abuse policy, which requires reporting all abuse allegations within two hours to the state survey agency, law enforcement, and the Ombudsman.
A resident with ALS and major depressive disorder, who was cognitively intact and dependent for ADLs, reported that a CNA made an inappropriate sexual thrusting gesture on a stool in the resident’s room, which the resident perceived as mocking his sexual orientation. The resident informed the DSD, who acknowledged being a mandated reporter but did not report or initiate an investigation. A CNA and the DON both characterized such conduct as a form of abuse that should be reported. Facility P&Ps required prompt, thorough investigation of abuse allegations and defined abusive conduct to include disparaging or derogatory gestured language, but these procedures were not followed in this case.
A resident with multiple serious health conditions experienced a delay in care after abnormal lab results were not promptly communicated to the physician as required. Nursing staff failed to document or directly notify the physician, instead sending lab results via text message, which was not the physician's preferred method. As a result, the resident's transfer to a hospital for treatment of severe dehydration, hypernatremia, and acute kidney injury was delayed.
A LVN did not document abnormal lab results or their communication to a physician for a resident with complex medical conditions, despite facility policy requiring such documentation. Instead, the LVN texted photos of the lab results to the physician and did not enter this information into the medical record, resulting in incomplete and inaccurate records and potential disruption of care continuity.
A resident with ALS, diabetes, and major depressive disorder, who was cognitively intact, filed multiple grievances about care and rights violations. Despite repeated requests, neither the resident nor their responsible party received written updates or resolutions, as required by facility policy. Staff confirmed that only verbal updates were given, leading the resident to escalate concerns to the state health department.
A resident with ALS, diabetes, and depression experienced symptoms including headache, cough, congestion, and fear of choking, but the nurse only notified the physician about cough and congestion via text, omitting key symptoms. The physician did not respond during the nurse's shift, and there was no follow-up call or escalation to the DON or Medical Director. The resident's condition worsened, leading to a hospital transfer and diagnosis of pneumonia and hypoxia. Documentation of communication and events was incomplete.
A resident with ALS, diabetes, and depression experienced cough, congestion, and fear of choking overnight. The nurse notified the physician by text about some symptoms but did not communicate the resident's fear of choking or shortness of breath. The physician did not respond for over eight hours, and the nurse did not escalate the issue to the DON or Medical Director as required by policy. The resident's family later called 911, and the resident was hospitalized with pneumonia and hypoxia.
A resident with ALS and intact cognition was not treated with dignity when a CNA removed his glasses without consent during care, leading to feelings of violation and distrust. Additionally, the resident was not provided with an admission packet or orientation, leaving him unaware of his rights and facility policies. Staff interviews confirmed these omissions, which resulted in the resident's confusion and lack of trust in the care team.
A resident with ALS, fully dependent on staff for transfers, was injured when a mechanical lift tipped and the sling bar struck the resident's head during a transfer. The incident occurred without a required physician order for lift use, resulting in head and chest contusions and hospital evaluation.
A resident who was alert and continent, but dependent on staff for toileting hygiene due to ALS, was not properly assessed or placed on a toileting program. Staff failed to assist the resident in a timely manner to use a urinal, instead encouraging use of an incontinence brief for staff convenience, which led to the resident being left in soiled conditions and feeling humiliated. Facility policies requiring continence assessment and individualized care planning were not followed.
A resident with ALS, depression, and diabetes refused to accept medications from an LVN due to concerns about respect. The LVN pre-charted the medications in the MAR before administration, and after the resident refused, another LVN prepared and administered new medications. The MAR was not updated to reflect the correct nurse or the resident's refusal, resulting in inaccurate documentation.
The facility failed to secure controlled drugs, including Oxycodone and Lorazepam, as per policy. A resident's Oxycodone was found in an unlocked drawer, and Lorazepam was not locked in the medication refrigerator. This involved residents with fibromyalgia and epilepsy, respectively.
The facility failed to follow professional standards for food service safety, as observed in the improper labeling and dating of food items and inadequate cleaning of kitchen equipment. Sack lunches for residents going out for dialysis were not labeled with preparation dates, and a container of liquid eggs was found open without an open date. Additionally, a can opener had a black sticky substance, indicating it was not cleaned as required. These deficiencies could lead to pathogen exposure and foodborne illnesses.
The facility failed to ensure that two residents had completed advance directive acknowledgments and POLST forms in their medical records. One resident, with developmental disorder and psychosis, lacked decision-making capacity, and the forms were sent to the Regional Center but not followed up. Another resident, with multiple diagnoses and severe cognitive impairment, also lacked a completed advance directive. The facility's policy requires these forms to be maintained, but the lack of follow-up and documentation led to incomplete records, potentially delaying care during emergencies.
The facility failed to implement comprehensive care plans for two residents, one with an intellectual/developmental disability and another using a bipap machine. The first resident lacked a care plan addressing their IDD, while the second resident's care plan did not cover bipap use, leading to issues with the humidifier. The facility's policy requires person-centered care plans, but these were not developed, potentially affecting the residents' quality of life.
A resident with end-stage renal disease and diabetes did not receive adequate dialysis care. The facility failed to update the resident's hemodialysis schedule, document refusals, or notify the MD of missed sessions. Out-of-range A1C levels were not reported, and the resident did not receive appropriate snacks on dialysis days. These deficiencies highlight a breakdown in communication and documentation within the facility.
The facility failed to administer medications as ordered for two residents, leading to a deficiency in pharmaceutical services. One resident with schizophrenia and other mental health disorders had several medications not documented as administered, while another resident with dementia and psychotic disorder also experienced lapses in medication administration. The Director of Nursing confirmed that physician orders should always be implemented as ordered.
The facility failed to implement nonpharmacological interventions for two residents prescribed PRN psychotropic medications. One resident with schizophrenia and dementia exhibited aggressive behaviors and was given Lorazepam without prior nonpharmacological measures. Another resident with dementia and anxiety was prescribed Xanax PRN without such interventions. Interviews confirmed the absence of these measures, contrary to the facility's policy.
Two residents in an LTC facility experienced medication administration errors, leading to a 23.08% error rate. One resident received enteric-coated aspirin instead of chewable aspirin, while another received five medications crushed together, contrary to facility policy. Staff failed to follow physician orders and best practices for medication administration.
The facility failed to properly label and store medications, affecting two residents. Bubble packs for medications lacked necessary instructions, insulin vials were not dated, and expired Vitamin K was found in the emergency kit. Saline solutions were stored insecurely, contrary to facility policies.
The facility failed to ensure proper infection control practices, as staff did not follow Enhanced Barrier Precautions or perform necessary hand hygiene and glove changes during resident care. An LVN did not wear an isolation gown while administering medications through a G-tube, and CNAs neglected hand hygiene and PPE use, risking infection spread among residents with severe cognitive impairments and those on dialysis.
A CNA failed to maintain a resident's dignity during meal assistance by standing over and rushing the resident to eat, despite being advised to sit at eye level. The resident, with developmental disorder and dysphagia, requires meal assistance. Facility policy emphasizes feeding with dignity, which was not followed in this instance.
A resident with dementia and no decision-making capacity signed Medicare-related documents without proper assessment or involvement of their responsible party. The facility's BOM did not verify the resident's capacity or consult nursing staff, leading to the resident's family being uninformed and concerned about potential costs and loss of appeal rights.
A facility failed to itemize a resident's belongings upon admission, resulting in lost items. The resident, with conditions including end-stage renal disease and major depressive disorder, reported missing a blanket and clothes. The Social Services Director and Registered Nurse Supervisor acknowledged the oversight, which violated the facility's policy requiring documentation of personal belongings upon admission.
A resident with multiple health conditions was transferred to a hospital due to vomiting and shortness of breath, but the facility failed to complete the necessary transfer form. This omission led to the receiving facility lacking essential information, as confirmed by interviews with the RN Supervisor and DON.
Two residents with dementia were involved in a physical altercation due to the facility's failure to implement their care plans. One resident, with a history of aggression, was not placed near the nursing station for monitoring, allowing them to approach another resident's bedside. The second resident, also with a history of aggression, scratched the first resident during the altercation. Additionally, the first resident missed three doses of Memantine, a dementia medication, which may have contributed to their behavior.
A facility failed to follow a pharmacy recommendation to repeat a Hemoglobin A1C test for a resident with diabetes and end-stage renal disease. Despite the pharmacy consultant's advice, the test was not ordered, and results were not communicated to the MD. Both the RN Supervisor and DON acknowledged the oversight, which was contrary to the facility's policy requiring notification of abnormal results.
Two residents with histories of aggressive behavior were involved in a physical altercation due to the facility's failure to monitor one resident as required by their care plan. Despite a care plan intervention to keep the resident near the nursing station for closer supervision, they were not placed accordingly, leading to the incident.
A resident with Parkinson's disease was not readmitted to the facility after hospitalization due to combative behavior and drug paraphernalia possession. Despite being cleared for return by the GACH, the facility did not honor the bed-hold policy, resulting in the resident staying at the hospital for two extra days. The facility's DON suggested the resident needed a substance abuse program, and the resident's bed was given away.
A resident with cognitive impairment and mobility issues was left in soiled incontinence briefs for over two hours, despite informing a CNA of the need for care. The CNA delayed assistance due to lunch service, and the resident remained unattended even after lunch trays were cleared. Facility staff confirmed the availability of a buddy system and team leaders to assist when needed, but these resources were not utilized, resulting in neglect of the resident's hygiene needs.
A facility failed to ensure proper management of psychotropic medications for two residents. One resident lacked a medical diagnosis for Depakote use, while another had PRN psychotropic orders without specified duration, frequency, or non-pharmacological interventions. Both residents did not have informed consent documented for their medications, contrary to facility policies.
A resident with cellulitis and stasis dermatitis did not receive prescribed medications on time due to a lack of communication and verification processes in the facility. Medications were delivered but not administered promptly, with Ciprofloxacin given six days late and Ammonium Lactate five days late. Staff interviews revealed unawareness of orders and absence of a system to verify medication deliveries against physician orders.
A resident with bipolar and schizoaffective disorders eloped from an LTC facility due to inadequate supervision. The resident was last seen in his room and was reported missing after staff failed to monitor the front entrance effectively. The resident was found 14 hours later, highlighting lapses in the facility's elopement prevention policy and staff coverage.
A resident, discharged AMA and no longer under facility care, had a gastrostomy tube removed at the LTC facility by a PA in the DON's office without proper orders. The resident, with dysphagia and intact cognition, was initially admitted with a GT. After discharge, the resident's responsible party returned to the facility for the procedure due to safety concerns, bypassing the facility's admission policy requiring physician orders.
A facility failed to ensure dermatology consultation notes were available in a resident's medical record, leading to delayed treatment. The resident, admitted with cellulitis, returned from a dermatology appointment with no new orders documented. Staff interviews revealed a lack of follow-up to obtain the consultation notes, which the DON confirmed, acknowledging the risk of missed treatment. Facility policy requires records to be legible and readily available, which was not followed.
A resident tested positive for Candida Auris, but the facility delayed initiating a Change of Condition form and obtaining physician's orders for infection prevention measures. Despite being informed by a hospital, the facility did not implement Enhanced Barrier Precautions until the following day, placing other residents and staff at risk. The facility's policies require immediate action for infection control, which was not followed in this case.
The facility failed to maintain a safe and homelike environment in a shower room, with eight missing and two cracked tiles observed. The Maintenance Supervisor admitted the tiles had been in disrepair for six months, posing a risk of accidents and germ exposure. The Administrator acknowledged the safety risk, which contradicts the facility's policy for a safe and comfortable environment.
The facility failed to conduct required IDT meetings for four residents with physician orders to go out on pass, violating their rights to participate in care planning. Despite having intact cognition and decision-making capacity, the residents were not assessed by the IDT as per facility policy, which the DON was unaware of.
A resident did not receive prescribed eye medications for four days after cataract surgery due to the facility's failure to clarify postoperative orders with the physician. Despite attempts by a nurse to contact the physician, the orders were not confirmed, delaying the administration of necessary medications.
Failure to Care Plan and Implement Fall-Prevention Interventions for a High-Risk, Non-Communicative Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, person-centered care plan with measurable objectives and timetables for a resident who was at high risk for falls and unable to effectively communicate his needs. The resident was admitted and later readmitted with diagnoses including subarachnoid hemorrhage, muscle weakness, failure to thrive, and a history of falls. An MDS dated 1/27/2026 showed moderately impaired cognition and complete dependence on staff for all ADLs. Upon readmission, the nursing admission assessment on 2/10/2026 identified the resident as a high fall risk and documented that he was alert and oriented only to name, and a subsequent MDS indicated severely impaired cognition and continued total dependence for ADLs. The resident’s care plan dated 1/23/2026 identified him as being at risk for falls due to unawareness of safety needs, a diagnosis of traumatic subdural hemorrhage, and a history of falls. The goal was for the resident to be free from falls, and interventions included ensuring the call light was within reach and encouraging him to use it to call for assistance. However, the care plan did not include interventions addressing his disorientation or his inability to communicate his needs or use the call light because of confusion. After the resident experienced an unwitnessed fall on 2/11/2026, documented in an SBAR and Unwitnessed Fall Report as being found on his knees with urine on the floor and unable to describe the event due to disorientation, the updated care plan on 2/11/2026 again failed to add interventions targeting his confusion and inability to communicate or use the call light. The resident sustained a second unwitnessed fall on 2/12/2026, documented in an SBAR and Unwitnessed Fall Report as being found in a sitting position on the floor with facial grimacing due to buttock pain and an ordered hip X-ray, and again was unable to describe the event due to disorientation. Predisposing fall factors on both fall reports included confusion, gait imbalance, incontinence, and recent admission within the last 72 hours. An IDT Post Event Review on 2/13/2026 identified contributing factors to the two falls as the resident’s diagnoses, comorbidities, functional and cognitive limitations, recent readmission with an unfamiliar environment, adjustment period, and impaired safety awareness, and indicated that the care plan was to be updated with specific fall-prevention interventions. However, review of care plans from 2/16/2026 to 4/24/2026 showed no documentation that ordered interventions such as a low bed with bilateral floor pads, a tab alarm in bed, and bilateral grab bars were added to the care plans. In interviews, RN 1 and the DON acknowledged that the resident’s confusion and need for increased monitoring and fall-prevention interventions were not addressed in the care plan at admission or after the falls, and that the omission of interventions discussed by the IDT was an oversight.
Failure to Complete and Document Timely Initial Physician Assessment for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the attending physician conducted and documented a timely initial history and physical (H&P) assessment for a newly admitted resident. The resident was admitted with serious neurological diagnoses, including subarachnoid hemorrhage and cerebral infarction, and had severely impaired cognition, required two-person assistance for ADLs, and was incontinent of bowel and bladder. Review of the medical record for the month following admission showed no documentation that the attending physician evaluated the resident, completed an H&P, or wrote any progress notes. The Medical Records Assistant confirmed that there was no evidence the physician had seen the resident, despite the physician being in the facility and seeing other residents during that period. The Medical Record Director stated that the attending physician was notified of the admission but that no follow-up reminder call was made after the initial notification. The attending physician acknowledged not following the facility’s policy on physician services and visits, explaining that she typically sees residents on specific days of the week and was unsure whether she had been reminded of the admission; she stated that she should have completed the initial assessment and documentation. The DON stated that the physician was supposed to perform a physical examination within three days of admission to identify the resident’s current condition and inform the resident and responsible party of goals, care, and treatment services. The facility’s written policy required the attending physician to perform a patient evaluation, including a written report of the physical examination, within five days prior to admission or within seventy-two hours after admission, which did not occur for this resident.
Failure to Accurately Document ADL Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate documentation of activities of daily living (ADLs) for one resident by a CNA. The resident, who had diagnoses including subarachnoid hemorrhage and cerebral infarction, was severely cognitively impaired per the Minimum Data Set and required two-person assistance for ADLs such as bathing, dressing, transferring, and repositioning, and was incontinent of bowel and bladder. The resident’s care plan documented a self-care deficit for ADLs and included interventions for maximal assistance with all ADLs, repositioning every two hours, and pressure-injury prevention measures. However, review of the resident’s Task Sheet for a specific date showed no documentation of ADL care provided during the 3 p.m. to 11 p.m. shift. During a telephone interview, the CNA assigned to the resident for that shift stated she had provided ADL care, including oral care, incontinence care, and repositioning, but admitted she forgot to document these tasks on the Task Sheet. Concurrent review of the Task Sheet with the Director of Staff Development confirmed there was no documentation of ADL care for that shift. The DON stated that all nursing staff are responsible for timely documentation of each resident’s status and response to care so that medical records remain complete and accurate. Facility policies on Nursing Documentation and Medical Record Content required concise, clear, pertinent, and accurate documentation of resident status and care, including ADLs, by the CNA who provided the care according to the date and shift, and maintenance of a medical record sufficient to support diagnoses, justify medical necessity, and facilitate continuity of care.
Failure to Protect Resident From Verbal Abuse During Care
Penalty
Summary
The facility failed to protect a resident’s right to be free from verbal abuse when a CNA used foul language in the resident’s presence during care. The resident had been admitted with diagnoses including cerebral infarction and PTSD, and an MDS assessment indicated intact cognition with a need for maximal assistance with toileting, bathing, and dressing. A Change in Condition note documented that the resident expressed concern about the CNA’s use of foul language in her presence. The facility’s investigation summary later confirmed that the CNA used an inappropriate word while inside the resident’s room. In an interview, the CNA stated that while in the resident’s room she spilled a cup of water and cursed in front of the resident, acknowledging that this could make the resident feel upset and uncomfortable. The DON also confirmed that the CNA used foul language in front of the resident and that the resident reported she did not appreciate the CNA blurting that out in front of her. The facility’s abuse prevention and prohibition policy stated that each resident has the right to be free from abuse and that the facility is committed to protecting residents from abuse by anyone, including staff. Another facility policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance, regardless of age, ability to comprehend, or disability.
Failure to Report Resident’s Allegation of Sexually Inappropriate Staff Conduct
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) as required under F609. A cognitively intact resident with diagnoses including amyotrophic lateral sclerosis (ALS) and major depressive disorder, who was dependent for ADLs, reported that a CNA made an inappropriate sexual gesture while providing personal care. The resident stated that the CNA thrust his pelvic area against a gray stool in the room in a way the resident found offensive and felt was mocking his sexual orientation as a gay man, which made him feel angry. The resident reported this incident to the Director of Staff Development (DSD), whom he identified as a mandated reporter. The DSD confirmed in interview that the resident had reported the CNA’s inappropriate gesture and that the resident felt the CNA was mocking his lifestyle because he is gay. The DSD acknowledged she is a mandated reporter and that the allegation should have been reported for the resident’s safety and to ensure a proper investigation, but she did not report it. The DON stated that the DSD should have reported the allegation immediately, that the allegation was a form of abuse, and that it should have been reported so a proper investigation could be conducted and the resident could be monitored for emotional distress. Review of the facility’s Abuse Prevention and Prohibition Program policy indicated that allegations of abuse must be reported immediately, but no later than two hours after forming a suspicion, to the state survey agency, law enforcement, and the Ombudsman, which did not occur in this case.
Failure to Investigate Resident’s Allegation of Sexual Abuse Gesture
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse Prevention and Prohibition Program by not investigating an allegation of sexual abuse made by a resident. The resident, who had diagnoses including amyotrophic lateral sclerosis (ALS) and major depressive disorder, had intact cognition per a recent MDS and was dependent for ADLs. During an interview, the resident reported that a CNA made an inappropriate sexual thrusting gesture with his pelvic area on a stool in the resident’s room, which the resident found offensive and perceived as mocking his sexual orientation as a gay man. The resident stated he reported this incident to the Director of Staff Development (DSD) and believed, as a mandated reporter, the DSD should have reported the allegation. The DSD confirmed in an interview that the resident had informed her about the CNA’s inappropriate gesture and that the resident felt the CNA was mocking his lifestyle, but she did not report the allegation. The DSD acknowledged she is a mandated reporter and that the allegation should have been reported. Another CNA stated that any inappropriate sexual thrusting gesture is considered a form of abuse and should be reported for resident safety. The DON stated the DSD should have reported the allegation immediately, that the conduct described was a form of abuse, and that it could have made the resident feel offended and embarrassed. Review of the facility’s abuse-related P&Ps showed that verbal abuse includes gestured language with disparaging or derogatory terms and that the facility is required to promptly and thoroughly investigate reports of resident abuse, including suspending accused staff until the investigation is complete. These required investigative steps were not initiated in response to the resident’s allegation.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
A deficiency occurred when abnormal laboratory results for a resident were not reported to the resident's physician in a timely manner, nor were instructions for care obtained promptly. The laboratory results, which included significant abnormalities such as elevated sodium, blood urea nitrogen (BUN), creatinine, and liver enzymes, were received by the facility in the afternoon. Despite the facility's policy requiring notification of abnormal results to the physician, there was no documentation that the physician was notified on the day the results were received. The resident had a complex medical history, including acute kidney failure, cerebral infarction, and congestive heart failure, and was unable to make reasonable decisions according to the Minimum Data Set. The abnormal lab results indicated severe dehydration, hypernatremia, and impaired kidney and liver function. Nursing staff on the relevant shifts failed to document follow-up or notification of the physician. One nurse texted the results to the physician, contrary to the physician's stated preference for phone calls, and did not document the communication in the resident's progress notes. The physician acknowledged receipt of the text but did not review the results at that time, and no further action was taken until the following day. The delay in notifying the physician and obtaining care instructions resulted in a delay in transferring the resident to an acute care hospital for evaluation and treatment. When the physician was finally contacted the next day, the resident was transferred and treated for severe dehydration, hypernatremia, hypotension, and acute kidney injury. Interviews with staff and the physician confirmed that the facility's expectations and the physician's preferences for communication were not followed, leading to the delay in care.
Failure to Document Lab Results and Physician Communication
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to document laboratory results and the communication of those results for a resident with multiple serious diagnoses, including acute kidney failure, cerebral infarction, and congestive heart failure. The resident was unable to make reasonable and consistent decisions, as indicated by their Minimum Data Set assessment. Physician orders required several lab tests, which were performed and returned with multiple abnormal results, including elevated white blood cell count, abnormal electrolyte levels, high blood glucose, impaired kidney function, and abnormal liver function tests. Despite the receipt of these abnormal lab results, there was no documentation in the resident's nursing progress notes to indicate that the results were communicated to the physician on the day they were received. The LVN stated that she printed the lab results, took photos, and texted them to the physician, believing that this method was sufficient and that further documentation in the medical record was unnecessary. This practice was contrary to facility policy, which required all care and communications, including lab data and their disposition, to be documented in the resident's medical record. The Director of Nursing confirmed that it was the responsibility of all licensed nurses to document all care provided, including communication with physicians, in the resident's medical record. Facility policies reviewed also emphasized the need for accurate and complete documentation of residents' status, care, and laboratory data in the medical record. The lack of documentation resulted in an incomplete and inaccurate depiction of the resident's well-being and had the potential to disrupt continuity of care.
Failure to Provide Written Grievance Outcomes to Resident
Penalty
Summary
The facility failed to provide the results of multiple grievances filed by a resident and/or their responsible party. The resident, who was diagnosed with amyotrophic lateral sclerosis (ALS), diabetes type 2, and major depressive disorder, was cognitively intact and able to communicate effectively. Despite submitting several grievances regarding perceived violations of resident rights and substandard care, neither the resident nor their responsible party received written updates or resolutions regarding the status of these grievances, even after repeated requests. Documentation reviewed showed that the facility investigated the grievances, but there was no indication that the outcomes or resolutions were communicated in writing to the resident or their responsible party. Interviews with facility staff confirmed that while some outcomes were discussed verbally, the resident's specific request for written updates was not honored. The Social Services Director acknowledged that written communication should have been provided, and the Director of Nursing stated that timely updates are a resident right. The facility's own grievance policy required that residents or their representatives be informed of the findings and any corrective actions in a timely manner. However, the lack of written communication regarding the resolution of grievances led to the resident feeling stressed, helpless, and distrustful of the facility. The resident escalated the complaints to the state health department due to the lack of response from the facility.
Failure to Notify Physician of Complete Change of Condition and Inadequate Follow-Up
Penalty
Summary
The facility failed to ensure timely and complete communication with a resident's physician regarding a change of condition. A resident with diagnoses including ALS, diabetes type 2, and major depressive disorder experienced symptoms such as headache, cough, congestion, and expressed fear of choking and shortness of breath. The nurse on duty documented the resident's complaints and administered medications for headache and sore throat, but only notified the physician via text message about the cough and congestion, omitting the resident's fear of choking and shortness of breath. The nurse sent two text messages to the physician during the night shift, but did not receive a response during her shift and did not follow up by calling the physician, the DON, or the Medical Director as required by facility policy. The nurse endorsed the resident's care to the oncoming nurse without further escalation. The physician eventually responded to the text messages over eight hours later, but was not made aware of the full extent of the resident's symptoms, specifically the fear of choking and shortness of breath, which would have prompted different interventions. The resident remained anxious and symptomatic throughout the night, ultimately leading to the family calling 911 and the resident being transferred to a hospital, where he was diagnosed with pneumonia secondary to COVID-19 and hypoxia. Documentation was incomplete regarding the time, method of communication, and the content of the interaction with the physician, making it difficult to ascertain the sequence of events related to physician contact and response.
Failure to Ensure Timely Physician Response to Change of Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure a physician responded in a timely manner to a resident's change of condition. The resident, who had diagnoses including amyotrophic lateral sclerosis (ALS), diabetes type 2, and major depressive disorder, began experiencing symptoms such as headache, cough, congestion, and expressed fear of choking during the night shift. The resident was cognitively intact and able to communicate his symptoms and concerns, including shortness of breath and anxiety about lying down due to fear of choking. The nurse on duty administered medications for headache and sore throat, and documented the resident's complaints, but only notified the physician via text message about the cough and congestion, omitting the resident's fear of choking and shortness of breath. The nurse sent text messages to the resident's physician at two points during the night shift, but the physician did not respond until over eight hours later, after the shift had ended. The nurse did not escalate the situation by contacting the Director of Nursing (DON) or the Medical Director when the physician failed to respond, as required by facility policy. The resident continued to experience symptoms and anxiety throughout the night, remaining upright to ease breathing, and felt that the nursing staff did not believe the severity of his symptoms. The following morning, the resident's family called 911, and the resident was transferred to a general acute care hospital, where he was diagnosed with pneumonia secondary to COVID-19 and hypoxia. Interviews with the resident, the nurse, the physician, and the DON confirmed that the physician was not informed of the full extent of the resident's symptoms, particularly the fear of choking and shortness of breath. The physician stated that he would have ordered additional interventions if he had been made aware of these symptoms. Facility policy required immediate escalation to the DON or Medical Director if the attending physician could not be reached, but this was not done. Documentation and interviews confirmed the delay in physician response and the lack of appropriate escalation.
Failure to Ensure Resident Dignity and Inform Resident of Rights
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) removed a resident's glasses from his hands without his permission while turning him in bed. The resident, who had diagnoses including amyotrophic lateral sclerosis (ALS), major depressive disorder, and type 2 diabetes, was cognitively intact and able to make his own decisions. The CNA did not obtain consent before taking the resident's personal belonging, and the resident reported feeling violated and distrustful of the staff as a result. The Director of Nursing (DON) and the Administrator both acknowledged that staff should not remove personal items from residents without permission, and the facility's policy confirmed this requirement. Additionally, the facility failed to provide the resident with an admission packet, which included the resident's bill of rights and information about facility policies and procedures. The Admission Coordinator admitted that the resident had not received this information or an orientation, despite having been in the facility for over ten days. The resident expressed confusion about the facility's rules and expectations and stated that he was not informed about his rights or the facility's policies, which contributed to his feelings of distrust and resistance toward staff. Interviews with facility staff confirmed that it was the responsibility of the Admission Coordinator to provide the admission packet and orientation, but all staff were responsible for ensuring residents understood their rights and facility policies. The facility's policies and procedures required that residents be treated with dignity and respect, and that they be fully informed about their rights and the facility's expectations. The failure to follow these policies resulted in the resident being unaware of his rights and feeling disrespected and confused.
Resident Injury During Mechanical Lift Transfer Without Physician Order
Penalty
Summary
A deficiency occurred when a resident diagnosed with amyotrophic lateral sclerosis (ALS), who was dependent on staff for activities of daily living, was injured during a transfer from bed to wheelchair using a mechanical lift. The resident, who was cognitively intact and at risk for falls and injuries, was being assisted by four staff members when the mechanical lift tipped to the side as the resident leaned back into the sling. During the process of detaching the sling from the lift, the sling bar struck the resident on the forehead, resulting in pain and subsequent transfer to a general acute care hospital for evaluation and treatment. The resident was found to have head and chest contusions and was treated for pain before returning to the facility. The facility's policy required a physician's order for the use of a mechanical lift, but review of the clinical records revealed that no such order was present for this resident. The Director of Nursing confirmed that the absence of a physician's order and the failure to ensure the resident's safety during the transfer led to the injury. The incident was documented in the resident's care plan and clinical records, and the facility's policy on mechanical lift use was not followed.
Failure to Provide Timely Toileting Assistance and Maintain Dignity for Continent Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident who was alert, continent of bowel and bladder, and at high risk for pressure ulcer development. Nursing staff did not assist the resident in a timely manner to use the urinal, which was necessary to maintain bladder continence. Instead, the resident was encouraged to use an incontinence brief for staff convenience, as staff were busy with other residents, resulting in the resident being left in soiled conditions and experiencing embarrassment and discomfort. The resident's care plan and Interdisciplinary Team (IDT) assessment were not implemented to address his toileting needs. The resident was not assessed for a toileting program upon admission, and his toileting habits and needs were not discussed with him. Staff did not inquire about his continence status, and he was admitted wearing an incontinence brief, leading to the assumption that he was incontinent. The resident required assistance with holding the urinal and cleaning himself due to his medical condition, but staff only responded to his needs when he specifically requested help, and there was no scheduled toileting program in place. Interviews with staff and review of facility policies confirmed that the resident's continence status was not properly assessed or documented, and a care plan addressing his bowel and bladder needs was not developed. The lack of timely assistance and failure to respect the resident's dignity resulted in the resident feeling humiliated and increased his risk for skin breakdown. Facility policies required continence assessments and individualized care plans, but these were not followed in this case.
Inaccurate Medication Administration Documentation Due to Improper Charting and Resident Refusal
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to accurately document medication administration for a resident with amyotrophic lateral sclerosis (ALS), major depressive disorder, and type 2 diabetes. The resident, who was cognitively intact and able to make decisions, refused to accept medications from one LVN due to concerns about dignity and respect. The LVN prepared the medications and pre-charted their administration in the Medication Administration Record (MAR) before actually giving them to the resident. When the resident refused to take the medications from the first LVN, the medications were handed to a second LVN. The resident also refused to take the medications prepared by the first LVN, leading the second LVN to waste those medications and prepare a new set in the resident's presence, which the resident then accepted. Despite this, the MAR reflected the first LVN's initials for the administration, and the second LVN did not update the record to accurately show who administered the medications. Interviews with both LVNs confirmed that the first LVN pre-charted the medications and did not document the resident's refusal as required by facility policy. The second LVN acknowledged not correcting the MAR to reflect the actual administration. The facility's policy and job descriptions require accurate, timely documentation by the nurse who administers medications, including proper notation of refusals and the identity of the administering nurse. This failure resulted in inaccurate documentation of medication administration for the resident.
Failure to Secure Controlled Drugs
Penalty
Summary
The facility failed to ensure proper safeguards for controlled drugs, leading to potential risks of theft, loss, and unauthorized consumption. Specifically, the facility did not double lock Oxycodone Hydrochloride 5 mg, a narcotic for pain relief, belonging to a resident. The medication was found in an unlocked drawer in the medication room, contrary to the facility's policy requiring double locking of Schedule II medications. The resident was admitted with a diagnosis of fibromyalgia and was alert and oriented at the time of the incident. Additionally, the facility did not secure Lorazepam, a Schedule IV drug used for treating anxiety, in a locked medication refrigerator as per the facility's policy. The medication refrigerator's padlock was found lying on top of the refrigerator, leaving the medication accessible. This oversight involved another resident with epilepsy, who had severely impaired cognition and required substantial assistance with daily activities. The Director of Nursing acknowledged the failure to secure these medications properly during interviews.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage and handling. During an observation and interview with the Dietary Supervisor (DS), it was noted that five sack lunches prepared for residents going out for dialysis lacked labels indicating the preparation date. Additionally, a 32-ounce container of pasteurized liquid whole eggs in the walk-in refrigerator was found open without an open date, which the DS confirmed should have been labeled to ensure freshness and proper discard timing. DA 1, who prepared the lunches, acknowledged the oversight in not dating the lunches. Further inspection revealed a large stationary can opener with a black sticky substance on its blade and base, indicating inadequate cleaning. The DS confirmed the presence of the substance and acknowledged the need for daily cleaning of the can opener. A review of the facility's policy and procedure documents indicated that the can opener should be sanitized between uses and that all food storage products should be labeled and dated. These practices, or lack thereof, had the potential to expose residents to pathogens and increase the risk of foodborne illnesses.
Failure to Complete Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 89 and Resident 2, had completed advance directive acknowledgments and POLST forms in their medical records. Resident 89, who was admitted with developmental disorder and psychosis, lacked the capacity to make decisions. The Social Service Director (SSD) stated that forms were sent to the Regional Center for completion but had no documentation to prove follow-up. The Medical Records Director (MRD) confirmed that the forms were faxed but had not received a response, leaving the advance directives incomplete in the resident's medical record. Resident 2, diagnosed with mild intellectual disability, paranoid schizophrenia, major depressive disorder, and cerebral infarction, was also found to be severely cognitively impaired and dependent on staff for self-care. The SSD indicated that paperwork was sent to the Regional Center for the advance directive acknowledgment form, but there was no record of when the fax was sent. The Director of Nursing (DON) emphasized the importance of having these forms to ensure proper treatment during emergencies. The facility's policy and procedure on advance directives require that residents be informed of their rights to execute an advance directive upon admission, and a copy should be maintained in their medical records. The policy also mandates that the Social Service Designee educate residents and families about healthcare decision-making and maintain communication to ensure resident self-determination. However, the lack of follow-up and documentation resulted in the failure to have completed advance directives for the residents, potentially delaying care and treatment during emergencies.
Failure to Implement Comprehensive Care Plans for Residents with Specific Needs
Penalty
Summary
The facility failed to implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident 2, who has an intellectual/developmental disability (IDD), did not have a care plan addressing their specific needs. The resident was admitted with multiple diagnoses, including mild intellectual disability, paranoid schizophrenia, major depressive disorder, and cerebral infarction due to thrombosis. Despite these conditions, the comprehensive care plans did not focus on the resident's IDD, likes, and dislikes. Interviews with the Registered Nurse Supervisor and the Director of Nursing highlighted the importance of a tailored care plan for communication, activities of daily living, and psychosocial needs, which were not addressed for Resident 2. Resident 50, who uses a bipap machine, also lacked a comprehensive care plan for their specific needs. The resident was admitted with diagnoses including paraplegia, acute and chronic respiratory failure with hypoxia, hypertension, and amyotrophic lateral sclerosis. The resident reported issues with the bipap machine's humidifier not being refilled by staff, causing distress and requiring the resident to set an alarm to check the humidifier at night. The MDS Coordinator confirmed the absence of a care plan for bipap use and emphasized the need for staff to conduct regular checks and interventions to ensure the resident's needs were met. The facility's policy on care planning requires a comprehensive, person-centered care plan for each resident based on their assessed needs. However, the facility failed to develop and implement such plans for Residents 2 and 50, potentially affecting their quality of life and well-being. The Director of Nursing acknowledged the importance of individualized care plans to guide staff in meeting each resident's unique needs, which was not achieved in these cases.
Inadequate Dialysis Care and Documentation for a Resident
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident with end-stage renal disease and type 2 diabetes mellitus. The resident's medical records were not updated to reflect a change in the hemodialysis schedule, which was reduced to twice a week per the resident's preference. This change was not documented by the Licensed Vocational Nurse, who admitted to forgetting to chart the new schedule. Additionally, the resident's refusal to attend hemodialysis sessions on multiple occasions was not documented, and no follow-up appointments were scheduled. The medical doctor was not notified of these refusals, and there was no monitoring of the resident post-refusal. The facility also failed to report out-of-range Hemoglobin A1C levels to the medical doctor. The resident's A1C levels were significantly higher than normal on two occasions, but the physician was not informed to obtain further orders or recommendations. This lack of communication and documentation could have impacted the resident's diabetes management and overall health. Furthermore, the facility did not provide appropriate snacks for the resident on hemodialysis days. The resident reported not receiving the necessary snacks, only a protein drink, which contradicted the dialysis center's recommendations. The facility lacked a system to track and document the provision of snacks, and the kitchen was closed during the resident's early morning dialysis sessions, leading to inadequate nourishment. This oversight could have resulted in potential health issues for the resident during dialysis.
Medication Administration Deficiency for Two Residents
Penalty
Summary
The facility failed to administer prescription medications as ordered for two residents, leading to a deficiency in pharmaceutical services. Resident 20, who was admitted with diagnoses including schizophrenia, anxiety disorder, major depressive disorder, and dementia, had several medications not documented as administered in November 2024. These medications included Mirtazapine, Vitamin C, Vitamin D, Colace, multivitamin, Sucralfate, and Quetiapine. The Minimum Data Set (MDS) for Resident 20 indicated severely impaired cognitive skills for daily decision-making, requiring assistance with various activities of daily living. Similarly, Resident 75, admitted with diagnoses of dementia, major depressive disorder, generalized anxiety disorder, and psychotic disorder, also experienced lapses in medication administration. The Medication Administration Record (MAR) for November 2024 showed that doses of Atenolol, Buspirone, Fluoxetine, Memantine, and Olanzapine were not documented as given. The MDS for Resident 75 indicated intact cognitive skills for daily decision-making, with varying levels of assistance required for daily activities. The Director of Nursing confirmed that physician orders should always be implemented as ordered, including medication administration, as per the facility's policy and procedure.
Failure to Implement Nonpharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to develop and implement nonpharmacological interventions for two residents who were prescribed PRN psychotropic medications. Resident 20, diagnosed with schizophrenia, anxiety disorder, major depressive disorder, and dementia, exhibited physical and verbal aggressive behaviors. Despite these behaviors, the facility did not have nonpharmacological measures in place before administering Lorazepam as needed for anxiety. Similarly, Resident 75, with diagnoses including dementia, major depressive disorder, generalized anxiety disorder, and psychotic disorder, was prescribed Xanax PRN for anxiety without prior nonpharmacological interventions. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the absence of nonpharmacological measures for both residents before administering PRN psychotropic medications. The facility's policy on behavior management, which mandates the use of nonpharmacological interventions before pharmacological ones, was not followed. This oversight had the potential to result in the unnecessary use of medications, placing the residents at risk of medication side effects.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications appropriately for two residents, resulting in a medication error rate of 23.08%. Resident 9, who was admitted with a history of transient ischemic attacks and cerebral infarction, was supposed to receive chewable aspirin for stroke prophylaxis. However, during the medication pass, Licensed Vocational Nurse (LVN) 2 administered enteric-coated aspirin instead of the prescribed chewable aspirin. This error was confirmed by Registered Nurse Supervisor (RN) 1, who emphasized the importance of following physician orders. Resident 16, diagnosed with dementia, hypertension, and psychosis, was observed receiving five medications crushed together and mixed with applesauce by LVN 3. The medications included metoprolol, Valsartan, Quetiapine, Docusate sodium, and Escitalopram. The facility's policy and procedure indicated that each medication should be crushed and administered separately to ensure safety and accuracy. The Director of Nursing (DON) reiterated that medications should be administered individually to identify any medication that might be spit out by the resident. These actions were contrary to the facility's policies and procedures for safe medication administration.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which led to several deficiencies. Two residents, one with intact cognitive skills and another with severely impaired cognitive skills, were affected by the lack of labeling on their bubble pack medications. The medications, Metoprolol and Amlodipine for one resident, and Metoprolol and Valsartan for the other, did not have the physician-ordered parameters for holding the medication based on systolic blood pressure and heart rate. Licensed Vocational Nurses confirmed that the bubble packs were not labeled with the necessary instructions, which should have been indicated for resident safety. Additionally, the facility did not label insulin vials with the date they were opened, which is necessary to ensure the medication's viability. During a medication storage check, it was observed that two vials of Lantus and one vial of Humulin R lacked the date of opening. Furthermore, Vitamin K in the emergency kit was found to be expired, and the Director of Nursing acknowledged that expired medications should not be stored for administration. The facility also failed to store saline solutions securely, as they were found in unlocked crash carts, making them accessible to unauthorized persons. The Director of Nursing stated that medications should be stored safely and securely, and expired medications should be removed from storage. The facility's policies and procedures were reviewed, indicating that medications should be stored in locked compartments and expired medications should be destroyed, but these were not followed in practice.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff members, leading to potential risks of infection spread among residents. In one instance, a Licensed Vocational Nurse (LVN) did not don an isolation gown while administering medications through a Gastrostomy tube (G-tube) for a resident who was severely cognitively impaired and dependent on staff for all activities of daily living. Despite the presence of an Enhanced Barrier Precaution (EBP) sign outside the resident's room, the LVN admitted to forgetting to wear the gown, which was necessary to prevent the spread of infection. In another case, a Certified Nurse Assistant (CNA) entered a resident's room without performing hand hygiene and did not wear personal protective equipment (PPE) while adjusting the resident's blanket. The resident was on Enhanced Barrier Protection due to a G-tube, and the CNA's actions were contrary to the facility's policy, which required hand hygiene and the use of gown, gloves, and mask to prevent infection transmission. Interviews with other staff members confirmed the necessity of these precautions, highlighting the risk of contaminating other residents with multidrug-resistant organisms (MDRO). Additionally, two CNAs failed to perform hand hygiene and change gloves during incontinence care for two residents. One resident had a history of dementia and infectious diseases, while the other was on dialysis with a permacath. Both CNAs did not change gloves between handling soiled and clean items, increasing the risk of cross-contamination. The facility's policy required glove changes and hand hygiene during such procedures, but the CNAs admitted to forgetting these steps, which could lead to the spread of infection among residents.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that staff treated a resident with respect and dignity during meal assistance. Specifically, a Certified Nurse Assistant (CNA) did not sit at eye level with the resident while assisting with feeding, instead standing over the resident and rushing her to eat. This behavior was observed during a meal service, where the resident, who has a developmental disorder and dysphagia, was being fed by CNA 6. Despite being advised by another CNA to sit down and not rush the resident, CNA 6 continued to stand and urge the resident to eat more, acknowledging later that this approach might have made the resident feel disrespected. The resident's medical records indicate she requires assistance with meals and has a consistent carbohydrate diet with pureed texture due to her condition. The facility's policy on meal assistance emphasizes feeding residents with attention to safety, comfort, and dignity, explicitly stating that staff should not stand over residents while assisting them. The Director of Nursing confirmed that staff should treat residents respectfully and not rush them during meals, as this could negatively impact their dignity.
Failure to Assess Mental Capacity Before Signing Medicare Documents
Penalty
Summary
The facility failed to assess the mental capacity of a resident before providing and obtaining signatures on important Medicare-related documents, specifically the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). The resident in question, who had been diagnosed with dementia and metabolic encephalopathy, was documented as having no capacity to understand and make decisions. Despite this, the resident signed the NOMNC and SNF ABN, which indicated the end of coverage for skilled services and potential costs for therapy services. The Business Office Manager (BOM) admitted to not being aware of the resident's lack of capacity and acknowledged that she should have consulted with the nursing staff before asking the resident to sign the forms. The Director of Nursing (DON) confirmed that if a resident lacks the capacity to understand and sign a form, the responsible party should be contacted to ensure they are informed and can exercise their rights, such as filing an appeal. The resident's family member was not informed about the signing of these documents, which caused concern and anxiety about potential costs and the loss of the right to appeal. The facility's policies and procedures require that a signature of acknowledgment be obtained from the beneficiary or their legal representative, and if a legal representative is involved, their authority must be verified. The facility's failure to adhere to these policies resulted in the resident and their family not being properly informed about their rights and responsibilities, potentially impacting their ability to appeal the decision regarding Medicare coverage.
Failure to Itemize Resident Belongings Leads to Loss
Penalty
Summary
The facility failed to adhere to its admission process by not itemizing a resident's personal belongings upon admission, leading to the loss of the resident's items. The resident, who was admitted with diagnoses including end-stage renal disease, major depressive disorder, and unspecified psychosis, was cognitively intact and required moderate assistance with daily activities. Upon reviewing the resident's admission record, it was found that there was no itemized list of belongings, which is a requirement according to the facility's policy. The resident reported missing items, including a blanket and clothes that were sent to the laundry and never returned. The Social Services Director was unaware of the missing items and acknowledged that the absence of an itemized list increased the risk of belongings being unaccounted for. The Registered Nurse Supervisor confirmed that the staff failed to follow the facility's admission procedure, which should have included creating an inventory of the resident's belongings. The facility's policy mandates that personal belongings be documented upon admission and that any complaints of misappropriation or theft be promptly investigated.
Failure to Document Transfer Form for Resident
Penalty
Summary
The facility failed to document a transfer form for a resident who was transferred to a general acute care hospital due to vomiting and shortness of breath. The resident, who had a history of congestive heart failure, acute respiratory failure, cerebral palsy, mild intellectual disabilities, and schizoaffective disorder, was noted to have repetitive emesis and shortness of breath. Despite the administration of medication for nausea and vomiting, the symptoms persisted, prompting an emergency medical transfer to the hospital. However, the necessary transfer form, which is crucial for communicating accurate information to the receiving facility, was not completed. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that the transfer form was not filled out, which led to the receiving facility having to contact the sending facility for information. The facility's policy requires documentation of the resident's transfer, and the omission of the transfer form was acknowledged as a failure to communicate essential information about the resident's condition and care provided prior to the transfer. This oversight had the potential to delay care at the receiving facility due to the lack of information.
Failure to Implement Dementia Care Plans Leads to Resident Altercation
Penalty
Summary
The facility failed to implement the dementia care plan for two residents, leading to a physical altercation. Resident 75, who had a history of aggression and resident-to-resident altercations, was not placed in a room close to the nursing station for close monitoring, as required by their care plan. This oversight allowed Resident 75 to approach Resident 20's bedside, resulting in a physical altercation where Resident 75 sustained scratches on the face. Resident 20, who had a history of aggression since June 2023, was involved in the altercation with Resident 75. The care plan for Resident 20 included interventions to prevent agitation and protect the safety of others, but these were not implemented effectively. As a result, Resident 20 was able to scratch Resident 75 during the altercation. Additionally, Resident 75 did not receive all scheduled doses of Memantine, a medication for dementia, with three doses missed in November 2024. This failure to administer medication as ordered could have contributed to the resident's aggressive behavior. The facility's policy on dementia care emphasizes the need for personalized care plans and consistent medication administration, which were not adhered to in this case.
Failure to Follow Pharmacy Recommendation for Hemoglobin A1C Test
Penalty
Summary
The facility failed to ensure that a pharmacy recommendation for a resident was followed through with the medical doctor. The resident, who was admitted with diagnoses including end-stage renal disease on dialysis and type 2 diabetes mellitus, had a Hemoglobin A1C test result of 8.6%, which is above the normal range. Despite the pharmacy consultant's recommendation to repeat the Hemoglobin A1C test, the order was not executed, and the results were not communicated to the medical doctor. Interviews and record reviews revealed that the Registered Nurse Supervisor acknowledged the oversight, stating that the pharmacy consultant's recommendation was not acted upon, and the results were not relayed to the medical doctor. The Director of Nursing also confirmed awareness of the pharmacy's recommendation and admitted that not following through was an oversight. The facility's policy requires that the ordering practitioner be notified of results outside of normal ranges, which was not adhered to in this case.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents, Resident 20 and Resident 75, from abuse, resulting in a physical altercation. Resident 75, who had a history of aggressive behavior, was not monitored closely as required by their care plan, which specified that they should be kept near the nursing station. This lack of supervision allowed Resident 75 to approach Resident 20, who also had a history of aggressive behavior, leading to a confrontation in Resident 20's room. Resident 20 was admitted with diagnoses including schizophrenia, anxiety disorder, major depressive disorder, and dementia, and had severely impaired cognitive skills. Their Minimum Data Set (MDS) indicated physical and verbal aggression towards others. Resident 75, admitted with dementia, major depressive disorder, generalized anxiety disorder, and a psychotic disorder, had intact cognitive skills but required supervision and assistance with daily activities. Despite the care plan intervention to monitor Resident 75 closely, they were not placed near the nursing station, which contributed to the incident. The altercation occurred when Resident 75, after hearing Resident 20 use a derogatory term, approached Resident 20's bedside, resulting in Resident 75 being scratched. The facility's policy on abuse prevention emphasizes zero tolerance for abuse and the need to protect residents from such incidents. However, the failure to implement the care plan intervention for Resident 75 led to the altercation, highlighting a deficiency in the facility's ability to prevent resident-to-resident abuse.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure the readmission of a resident after hospitalization, violating the bed-hold policy. The resident, who had Parkinson's disease and intact cognition, was transferred to a General Acute Care Hospital (GACH) due to combative behavior and possession of drug paraphernalia. Despite being cleared by the GACH for return, the facility did not readmit the resident, resulting in the resident remaining at the hospital for two additional days. The facility's census indicated the resident's room was marked as empty, and the bed was given away, despite the resident's request for a bed hold. The facility's Director of Nursing (DON) communicated to the GACH that the resident required a substance abuse program, suggesting the facility could not meet the resident's needs. The GACH's social worker reported that the facility believed the resident was being taken to jail and no longer had a bed available. The facility's policy stated that a bed would be held for up to seven days if the resident or their representative requested it within 24 hours of transfer, which was not honored in this case.
Neglect of Resident Due to Delayed Incontinence Care
Penalty
Summary
The facility failed to ensure that a resident was free from neglect when a Certified Nurse Assistant (CNA) left the resident with soiled incontinence briefs for over two hours. The resident, who was admitted with diagnoses including cancer of the intestines, gait abnormalities, and osteoporosis, was dependent on substantial assistance for personal hygiene. The resident's care plan required checks for incontinence every two hours. On the day of the incident, the resident informed CNA 1 at noon that she was wet and needed to be cleaned, but CNA 1 delayed the care, stating that lunch trays were being served and promised to clean the resident after lunch. Despite the lunch trays being picked up by 1:30 p.m., CNA 1 was observed sitting at the nurse's station and did not attend to the resident. The resident remained in soiled briefs until at least 2:10 p.m., when CNA 1 was seen assisting another resident. Interviews with other staff members, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed that the facility had a buddy system and team leaders available to assist if a CNA was too busy. The facility's policy required perineal care to prevent skin breakdown and maintain hygiene, which was not adhered to in this instance, leading to the resident feeling neglected and potentially at risk for skin issues.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that one of the sampled residents had a medical diagnosis indicated for the use of Depakote, a medication used to treat mental illness. The resident was admitted with diagnoses including major depressive disorder, dementia, and psychosis, but there was no specific medical diagnosis justifying the use of Depakote. This oversight was confirmed by the Registered Nurse Supervisor, who acknowledged that the absence of a medical diagnosis could lead to the unnecessary administration of the medication. Additionally, the facility did not adequately manage PRN psychotropic medications for another resident. The PRN orders lacked a specified duration, non-pharmacological interventions prior to use, monitoring for side effects and adverse reactions, and monitoring for hours of sleep. Furthermore, the PRN order for Xanax did not indicate a frequency, and other medications were ordered without a specified duration. These deficiencies were confirmed by the Director of Nursing, who emphasized the importance of informed consent and proper documentation to prevent unnecessary medication use. Both residents involved did not have informed consent documented for their psychotropic medications, which is a critical step to ensure that residents or their responsible parties are aware of the risks and benefits of the medications. The facility's policies and procedures require informed consent, a medical diagnosis for psychotropic medication orders, and thorough monitoring of psychotropic drug use, including the evaluation of non-pharmacological approaches before administering PRN medications. The failure to adhere to these policies resulted in the potential for unnecessary medication administration to the residents.
Delayed Administration of Prescribed Medications
Penalty
Summary
The facility failed to ensure that medications prescribed to a resident following dermatology visits were administered as ordered. The resident, who was admitted with cellulitis of the lower limbs, was prescribed several medications, including Ciprofloxacin, Mupirocin, Triamcinolone, Hibiclens, and Ammonium Lactate, to treat stasis dermatitis. These medications were delivered to the facility on the same dates they were prescribed, but there was a delay in their administration. Ciprofloxacin was administered six days after delivery, and Ammonium Lactate was applied five days after it was prescribed. Interviews with facility staff revealed a lack of communication and verification processes regarding medication orders and deliveries. Licensed Vocational Nurses and the Registered Nurse Supervisor acknowledged that medications were not administered promptly due to unawareness of the orders and failure to verify them against the delivery. The Director of Nursing admitted there was no system in place to ensure medications were checked against physician orders upon delivery. This deficiency resulted in delayed treatment for the resident's skin condition.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise and monitor a resident who lacked decision-making capacity, resulting in the resident eloping from the facility. The resident, who had been diagnosed with bipolar disorder and schizoaffective disorder, was last seen in his room at approximately 6:54 p.m. on 10/10/2024. The resident was reported missing at 7:57 p.m., and despite a search by facility staff, he was not found until the following day when his responsible party informed the facility of his whereabouts. The resident was missing for approximately 14 hours. Interviews and record reviews revealed lapses in supervision and monitoring. The facility's receptionist, who was responsible for monitoring the front entrance, took breaks without ensuring coverage, and the front entrance alarm was not activated until after the resident had already left. The facility's policy on wandering and elopement was not effectively implemented, as the resident was able to leave unnoticed. The facility's assessment tool indicated a need for sufficient staff with appropriate competencies to ensure resident safety, which was not met in this instance.
Unauthorized Medical Procedure on Discharged Resident
Penalty
Summary
The facility failed to ensure that a resident, who had been discharged against medical advice, did not undergo a medical procedure at the facility without being under the care of a physician. The resident, who had a gastrostomy tube due to dysphagia, was discharged from the facility and was no longer under the care of a physician there. Despite this, the resident returned to the facility with their responsible party to have the gastrostomy tube removed in the Director of Nursing's office by a physician assistant. This procedure was performed without any orders or instructions for care, as the resident was no longer admitted to the facility. The resident's medical records indicated that they had been admitted with a diagnosis of dysphagia and had a gastrostomy tube placed. The resident was found to have intact cognition and required moderate assistance with activities of daily living. After being discharged against medical advice, the resident's responsible party expressed concerns about the gastrostomy tube while the resident was out on the street, leading to the decision to have the tube removed at the facility. This action was taken despite the facility's policy that residents should only be admitted upon the order of an attending physician, highlighting a failure to adhere to established procedures.
Missing Dermatology Consultation Notes
Penalty
Summary
The facility failed to ensure that the consultation notes from an external dermatology visit were readily available in the medical record for a resident. This deficiency was identified during a review of the resident's clinical records, which showed no documentation of the dermatology consultation note. The resident, who was admitted with cellulitis of the lower limbs, had a dermatology appointment scheduled, and upon returning from the appointment, there were no new orders documented in the progress notes. Interviews with facility staff revealed that the Licensed Vocational Nurse did not follow up with the physician's office to confirm or obtain the consultation notes after the resident's return. The Director of Nursing confirmed the absence of the consultation notes and acknowledged the risk of missed treatment and medications if staff did not follow up to obtain necessary documentation. The facility's policy requires that records be maintained in a form that is legible and readily available, which was not adhered to in this case.
Failure to Implement Timely Infection Control for C-Auris
Penalty
Summary
The facility failed to initiate a Change of Condition (COC) form and obtain physician's orders for infection prevention measures for a resident who tested positive for Candida Auris (C-Auris), a multidrug-resistant fungal infection. The resident was readmitted to the facility with a history of candidiasis, MRSA, and ESBL resistance. On the evening of 7/15/2024, the facility was informed by a General Acute Care Hospital (GACH) that the resident had tested positive for C-Auris. However, the Director of Nursing (DON) decided to follow up with the hospital the next day, delaying the implementation of necessary infection control measures. The Infection Prevention Nurse (IPN) acknowledged that the resident should have been placed on Enhanced Barrier Precautions (EBP) immediately upon notification of the positive C-Auris test to prevent transmission. Despite being informed on 7/15/2024, the COC was not initiated until the following day, 7/16/2024, which delayed the application of infection prevention precautions. The IPN and Registered Nurse Supervisor (RNS) both confirmed that the COC should have been started immediately upon receiving the test results. The facility's policy and procedure for Resident Isolation and Change of Condition Notification require immediate action when a resident is known or suspected to be infected with transmissible microorganisms. The delay in initiating the COC and implementing infection control measures placed other residents and staff at risk of infection. The DON later acknowledged the importance of placing a PPE cart by the resident's room and ensuring staff wore gowns when providing care to prevent the spread of infection.
Facility Fails to Maintain Safe and Homelike Shower Environment
Penalty
Summary
The facility failed to provide a homelike environment for residents due to the presence of eight missing shower tiles and two cracked tiles in one of the two shower rooms. During an observation, five missing tiles were noted on the right side of the floor and three along the wall in the second shower stall, with two cracked tiles on the wall separating the first and second stalls. The Maintenance Supervisor acknowledged that the tiles had been in this condition for the past six months and expressed concern about the potential for resident injury. The Administrator also recognized the risk posed by the broken and missing tiles, acknowledging that they could lead to accidents and exposure to germs. The facility's policy, dated October 2023, mandates that the environment should be safe, clean, comfortable, and homelike, ensuring that the physical layout does not pose a safety risk. However, the current state of the shower room contradicts this policy, as it fails to provide a safe and homelike environment for the residents.
Failure to Conduct IDT Meetings for Residents Going Out on Pass
Penalty
Summary
The facility failed to implement its policy to conduct Interdisciplinary Team Meetings (IDT) for four residents who had physician orders to go out on pass for therapeutic purposes. This deficiency violated the residents' rights to participate in the development of their person-centered care plans. The residents involved had various diagnoses, including major depressive disorder, abnormalities of gait and mobility, dementia, and HIV, but all had intact cognition and the capacity to make decisions. Despite this, there was no documentation of IDT meetings to assess their ability to participate in activities outside the facility, as required by the facility's policy. During an interview, the Director of Nursing (DON) admitted to being unaware of the policy requiring IDT meetings before residents go out on pass. The facility's policy, dated 10/01/2023, mandates that the IDT assess the resident's decision-making capacity, physical disabilities, and ability to take medications independently before allowing them to go out on pass. The lack of IDT meetings meant that the residents and their representatives were not adequately informed or assessed regarding the process of going out on pass, which is crucial for ensuring their safety and understanding of the necessary procedures.
Failure to Administer Postoperative Eye Medications
Penalty
Summary
The facility failed to contact and inform the physician to clarify postoperative orders for a resident who returned from cataract surgery. This resulted in the resident not receiving prescribed eye medications, including Cyclogyl Ophthalmic solution, Phenylephrine HCL Ophthalmic solution, and Tropicamide Ophthalmic solution, for four days following the procedure. The resident, who had intact cognitive skills and required assistance with daily activities, was admitted with a diagnosis of type 2 diabetes mellitus. The deficiency was identified through interviews and record reviews, revealing that the resident returned with eye drops and verbal instructions to apply them every four hours, but no written orders were received. Despite attempts by a registered nurse to contact the physician, the orders were not clarified, and the medications were not administered until four days later. The Director of Nursing acknowledged that the staff should have immediately followed up with the physician to ensure the resident received the necessary postoperative medications.
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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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