Sunnyside Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrance, California.
- Location
- 22617 S. Vermont Ave, Torrance, California 90502
- CMS Provider Number
- 056488
- Inspections on file
- 71
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 28 (1 serious)
Citation history
Health deficiencies cited at Sunnyside Nursing Center during CMS and state inspections, most recent first.
Inconsistent Hot Water for Resident Bathing and Hygiene: Residents reported cold showers, missed baths, and staff heating water in a microwave because the boiler was not reliably producing hot water. CNAs confirmed the water was sometimes cold, especially later in the day, and the MS said he had received frequent complaints and that the boiler had malfunctioned and required repair. The DON stated bathing residents in cold water was not acceptable and that microwaving water for bathing was unsafe because the temperature could not be accurately determined.
Incorrect room clocks and inconsistent hot water affected resident care and comfort. A resident room clock displayed the wrong time, and staff said malfunctioning clocks were not working and needed repair. Multiple residents with conditions including DM, dementia, quadriplegia, and chronic pain reported cold sink or shower water, while CNAs said they sometimes had to microwave water for bed baths or avoid later showers because the water became cold. The DON stated bathing residents in cold water was not appropriate and that microwaving water for bathing was unsafe because staff could not accurately determine the temperature.
Staff failed to follow infection control practices during resident care and meal service. An LVN took a resident’s BP with an automated cuff, then repeated the BP with a manual cuff and stethoscope without hand hygiene or disinfecting the equipment. An AA distributed lunch trays, handled a pen and opened residents’ milk without hand hygiene. A CNA entered a resident’s room, handled items, and took vital signs without hand hygiene. The IP, DON, and staff interviews confirmed hand hygiene and disinfection of reusable equipment were expected.
Failure to maintain a resident’s privacy and dignity during care and in common areas. A resident with Parkinson’s disease, atrial fibrillation, limited decision-making capacity, and dependence for care was observed with the privacy curtain open during med pass, leaving legs and foley tubing visible from the hallway. The resident was later seen in a wheelchair in the hallway with legs exposed and catheter tubing visible; an OTA and the SNE stated this did not maintain dignity and that staff should keep residents covered and medical devices discreetly positioned.
Call lights were not within reach for three residents, including one resident who was awake in bed asking for help and unable to reach the device. The residents had significant care needs and varying levels of cognitive impairment, and an LVN and CNA acknowledged the call lights were not properly checked or positioned. The facility also provided a bed that was too short for a tall resident with DM and spinal stenosis; the resident said he had reported the issue, and staff observed his feet pressed against the foot board while the DON stated he should have a longer bed.
Inaccurate MDS coding for a resident. The facility failed to ensure the MDS accurately reflected the care and services provided for a resident with DM and dementia. During record review, the MDS nurse stated the resident was not on any anticoagulants and acknowledged the MDS was inaccurate. The DON stated the MDS must be completed accurately because it reflects the resident’s condition in real time.
A resident who was dependent for toileting hygiene, personal hygiene, and bathing was left in a wet incontinent pad and did not receive a bed bath as scheduled. The resident reported itching, scratching, and discomfort, and said the last perineal care had been hours earlier. CNA 1 answered the call light but did not ensure the needed care was provided, and CNA 2 did not change the resident before going on break.
A resident with anemia, HTN, and dementia did not receive ordered ferrous sulfate and carvedilol during a med pass. An LVN stated the iron was missed because the order was not seen on the computer screen, and the carvedilol was not given because it was unavailable. The DON stated meds should be administered as prescribed and must be available for nurses to give.
A resident with anemia, HTN, and dementia missed ordered doses of ferrous sulfate and carvedilol during medication pass. An LVN said the iron was missed because the order was not seen on the computer screen and the carvedilol was not given because it was unavailable; the DON stated medications must be administered as prescribed and available for nurses to give.
Expired medications and vaccines were found in medication rooms, including Gavilyte-G, pneumococcal vaccines, and COVID-19 vaccines. An open insulin e-kit was also observed that had not been replaced after it was accessed, despite facility policy stating expired medications must be removed and emergency kits replaced promptly.
Failure to provide dental services for a resident with tooth pain and an infected tooth. The resident had a dental consult showing a need for tooth extraction due to infection and a fistula, but the recommended follow-up was not completed. The resident later reported waiting to be seen by a dentist and still having pain. SSD and DON stated social services was expected to follow up with dental recommendations, and the facility policy says social services assists residents with appointments.
Late Lunch Tray Delivery: Two residents received lunch trays more than one hour late after residents were observed waiting in the dining room past the posted mealtime. One resident was independent with eating but needed some ADL assistance, and the other resident had ESRD, DM, anemia, and was dependent on staff for eating and other care. CNA stated she did not know why the trays were late, and the DON stated meal trays should be delivered on time.
Unsafe Food Storage, Thawing, and Cold Holding Practices: An open container of garlic powder, corn starch, kosher salt, and macaroni was found without open dates, frozen chicken was being thawed in stagnant water in the sink, and milk on the breakfast tray line was observed at 55 F. The Cook and DS stated that opened food must be dated, meat must be thawed in cold running water or the refrigerator, and cold foods including milk must be held at 41 F or lower.
Inaccurate medication documentation occurred for two residents. One resident’s MAR showed iron was given, but an LVN observed during med pass did not prepare or administer the ordered iron. Another resident’s MAR showed COVID-19 and PNA vaccines were administered, but both vaccines were later found in the med refrigerator, and an LVN stated she signs the MAR before actually giving meds and documented the vaccines in error. The DON stated meds should be administered as prescribed and documented after administration.
A resident with DM and dementia had hospice ordered for protein calorie malnutrition, but the facility did not merge the hospice plan of care with the facility care plan. Staff interviews confirmed there was no individualized hospice care plan reflecting hospice services. The resident also showed clinical improvement, including better intake, slowed weight loss, improved wounds, and a hospice MD noted the decline had slowed and the team was considering removing the resident from hospice, yet eligibility had not been reassessed.
Two residents experienced changes in condition that led to physician orders for a respiratory panel and a BMP, but staff did not ensure the ordered blood tests were collected and did not document any follow-up or physician notification when the tests were not performed. One resident with COPD and other chronic conditions had a new cough and loss of appetite, prompting an order for a respiratory panel that was never carried out. Another resident with heart failure, hypothyroidism, and AFib had episodes of diarrhea, nausea, and vomiting, leading to an order for a BMP that was not collected, as shown by the missing phlebotomist signature on the lab log. The IPN, DON, and ADON confirmed there was no documentation of lab follow-up or physician notification, and the facility’s lab/diagnostic test policy lacked procedures for tracking collection or notifying the physician when tests were not completed.
A resident with a history of fractures and normal cognitive function was roughly handled by a CNA during personal care, despite expressing a preference for shower timing and warning about a prior injury. The CNA, appearing rushed and overwhelmed, squeezed the resident's left hand hard while assisting with a gown, resulting in a purplish discoloration and emotional distress. The incident was corroborated by staff interviews and facility policy requiring respectful treatment was not followed.
A resident with cognitive and medical impairments was reportedly handled roughly by a male CNA during a night shift. The responsible party informed an LVN, but the LVN did not immediately report the allegation to the RN Supervisor or abuse coordinator as required. Staff interviews confirmed the delay, and the administrator only reported the incident to authorities several hours after learning of it, exceeding the required two-hour reporting window.
A nurse failed to review and clarify conflicting hospital discharge instructions for a resident with end-stage renal disease, resulting in the administration of Baclofen despite explicit instructions not to use it. The resident developed acute toxic encephalopathy and required hospital transfer and hemodialysis. The error occurred because the nurse did not follow facility policy to verify orders with the physician, leading to an Immediate Jeopardy situation.
A resident who required assistance with ADLs and expressed a strong preference for showers over bed baths was not consistently provided showers as requested. Documentation showed limited showers, multiple refusals of bed baths, and several undocumented shifts. Staff interviews confirmed the resident's preferences were known but not always accommodated, contrary to facility policy on respecting resident choices.
A resident with left side hemiplegia and a high fall risk was admitted and assessed using the Morse Fall Scale and interdisciplinary team review. Despite being identified as high risk for falls, the care plan did not include the facility's Fall Management Program interventions, such as a low bed, fall pad, colored wristband, or star magnet, as required by facility policy. Instead, only general fall prevention measures were documented, resulting in incomplete care planning for the resident.
A resident was administered Baclofen despite conflicting hospital discharge instructions and without physician clarification, resulting in adverse health effects and hospital transfer. The facility did not file an incident report or conduct a QAPI meeting to address the error, contrary to its policies.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility did not ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, or neglect by any individual.
The facility did not consistently implement required interventions to manage and prevent pressure ulcers, resulting in inadequate care for residents with or at risk for pressure ulcers.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs.
A resident with significant mobility limitations and no initial sacrococcyx wounds developed a severe, facility-acquired pressure injury after staff failed to consistently implement physician orders and facility policy for turning, repositioning, and incontinence checks. Documentation showed repeated missed interventions, lack of care plan updates, and no record of resident refusals, resulting in the progression of a pressure ulcer to stage 4 with infection and hospitalization.
A resident with significant mobility limitations and no initial sacrococcyx pressure injury developed a worsening wound after spending extended periods in a wheelchair without appropriate offloading interventions. Staff and family reported the absence of consistent pressure relief measures or care plan updates to address the resident's needs, resulting in the progression of a pressure injury from stage two to unstageable. The DON confirmed that the care plan lacked specific interventions for pressure relief while the resident was in the wheelchair.
A resident with impaired mobility and muscle weakness experienced a 30-day delay in receiving ordered PT and OT services due to the rehabilitation department's failure to follow up on therapy authorization. Despite facility policies assigning responsibility for timely tracking and implementation of therapy orders, the delay occurred, resulting in a significant gap before therapy was initiated.
A restorative nurse assistant failed to remove PPE and perform hand hygiene before exiting the room of a resident on Enhanced Barrier Precautions due to dialysis access and recent amputation. The staff member exited the room wearing gloves and a gown to retrieve an oxygen tank, contrary to facility policy and posted instructions, and later acknowledged the error during an interview. Facility leadership confirmed that PPE should be removed and hand hygiene performed before leaving such rooms to prevent infection transmission.
A resident with a history of anxiety and cognitive decline accessed unsecured rehab equipment without staff knowledge and used a dowel to physically assault two other residents, resulting in injuries including a sacral fracture. The rehab room door was not locked when unsupervised, and equipment was left accessible, contrary to facility policy requiring individualized safety interventions and supervision. Staff were unaware of the resident's access to the equipment until after the incidents occurred.
A resident accessed an unsecured rehabilitation dowel and used it to physically assault two other residents, resulting in one sustaining a sacral fracture and requiring hospital transfer. The rehabilitation room and its equipment were not consistently secured or supervised, and staff did not follow facility policy to prevent or address abuse.
A resident's responsible party reported multiple complaints about inadequate ADL care, which were not formally logged or investigated by the facility. The resident, with severe cognitive impairment and dependence on a ventilator, was found in soiled briefs and ungroomed. Despite discussions with an RN, the grievance process was not initiated, leading to a lack of formal investigation and follow-up, potentially delaying necessary care.
A facility failed to conduct timely IDT meetings for a resident with chronic respiratory failure and ventilator dependence, excluding the resident's Responsible Party (RP) from the process. Despite multiple hospitalizations and severe cognitive impairment, the last IDT meeting involving the RP was held months prior, leaving the RP without the opportunity to discuss concerns about the resident's care, including pressure ulcer management. The facility's policies require IDT involvement with the resident and family to develop and update care plans, especially after hospital readmissions.
A resident with chronic conditions experienced an incident where a water bottle fell on their foot, causing pain. The facility failed to document a Change of Condition, notify the physician and family, and conduct necessary assessments and monitoring. Despite a treatment plan for the resident's worsening toe condition, weekly assessments were not performed, revealing deficiencies in care and documentation.
A resident in a persistent vegetative state developed a Stage II pressure injury that progressed to Stage IV due to the facility's failure to provide consistent treatment and monitoring. The facility did not follow physician orders, lacked timely wound assessments, and delayed nutritional consultations, contributing to the deterioration of the pressure injury.
A resident at high risk for falls was left unsupervised in the bathroom by a CNA, contrary to the facility's fall prevention policy. The resident, who required assistance with ambulation and used a front wheel walker, attempted to walk back to bed alone and fell, resulting in multiple fractures. Staff interviews confirmed the resident's need for supervision, and the fall was deemed preventable.
The facility failed to properly store and label food, with Lysol bleach cleaner found in the dry food storage area, an unclean ice machine drain, and missing freezer temperature logs. Staff acknowledged the risks of contamination and serving expired food, violating facility policies.
Two residents experienced delayed care due to the facility's failure to respond to call lights promptly. One resident, with intact cognition and multiple health issues, was left in severe pain for over 25 minutes despite pressing the call light and calling for help. Another resident, with dementia and mobility issues, had the call light clipped out of reach, increasing the risk of falls. Staff acknowledged the importance of timely response, as per facility policy, but failed to meet these standards.
A facility experienced a 34.48% medication error rate due to improper administration and timing of medications for four residents. A resident did not receive a full dose of Amlodipine via GT, while another's BP was not reassessed before medication administration. Two residents received their medications significantly late, contrary to facility policy. These deficiencies highlight issues in medication administration practices.
A resident with a history of seizures and other conditions experienced significant medication errors due to late administration of prescribed medications, including Phenytoin, Phenobarbital, and Heparin. The medications were given several hours late on multiple occasions, contrary to the physician's orders. The LVN responsible did not inform the physician before administering the medications late, and the RN confirmed that such delays could lead to potential overdosing.
The facility failed to follow infection control practices, including not changing and labeling oxygen and feeding bags, improper PPE use by staff, and inadequate cleaning procedures. A visitor also did not wear PPE in a resident's room under contact isolation for Candida Auris.
A facility failed to maintain a resident's dignity during meal assistance when a CNA stood over the resident while feeding her, contrary to the facility's policy of providing a dignified dining experience. The resident, with severe cognitive impairments, required substantial assistance with eating. Staff interviews confirmed that proper procedure involves sitting at eye level to ensure comfort and prevent aspiration.
A facility failed to reassess the PASARR for a resident diagnosed with mental illness and placed on antipsychotic medication. The resident, with diagnoses including psychosis and anxiety disorder, was not reassessed for PASARR Level 1 after being placed on antipsychotic medication. The oversight was acknowledged by the Director of Medical Records and the Minimum Data Set Coordinator, who confirmed that the facility missed updating the PASARR Screening, potentially delaying necessary care and services.
Two residents in the facility experienced deficiencies in medication administration. One resident did not receive the full dose of Amlodipine due to improper mixing and administration via a gastrostomy tube. Another resident's blood pressure was not reassessed before administering medications with specific parameters, leading to potential risks. The facility's policies for medication administration and vital sign monitoring were not followed, impacting the care provided to these residents.
The facility failed to secure medication carts, leading to potential unauthorized access, and improperly stored home medications without a physician's order. Additionally, an opened medication lacked proper labeling, risking the use of expired medication. These deficiencies highlight lapses in medication security and adherence to facility policies.
A resident with diabetes and pulmonary hypertension did not have her food preferences honored, as the facility frequently ran out of requested items like bacon and cream of wheat. Despite documented preferences and a controlled carbohydrate diet, the resident received alternative foods, leading to dissatisfaction. Staff interviews confirmed that popular items often ran out, and the Dietary Supervisor admitted to not regularly engaging with residents unless complaints were made.
The facility's QAPI committee failed to establish a system for medication management, fall prevention, and pressure ulcer monitoring, resulting in medication errors, fall-related injuries, and inadequate pressure injury documentation. The Administrator could not provide evidence of preventive measures, despite the facility's policy indicating a need for a systematic process to improve resident care and safety.
A facility failed to follow its antibiotic stewardship program by administering antibiotics to a resident without meeting Loeb's or McGeer's criteria. The resident, with conditions like hemiplegia and neuromuscular bladder dysfunction, was given Ampicillin for a UTI without proper justification. The Director of QA confirmed the oversight, and the CCO noted potential risks of unnecessary antibiotic use.
A facility failed to offer, educate, and document influenza vaccinations for a resident with impaired cognition and dependency on care, as per its policy. Despite being eligible, there was no record of the vaccine being offered or declined. The Director of QA and CCO emphasized the importance of vaccinations to prevent infections, but the facility's procedures were not followed, resulting in a deficiency.
The facility failed to offer, educate, and document COVID-19 vaccinations for two residents, contrary to its policy. One resident with hemiplegia and another with chronic respiratory failure were eligible for the 2024-2025 vaccine, but there was no documentation of the vaccine being offered, education provided, or refusal recorded. The Director of QA confirmed the oversight, highlighting the importance of vaccination to prevent infection spread.
Inconsistent Hot Water for Resident Bathing and Hygiene
Penalty
Summary
The facility failed to ensure its water boiler was maintained and functioning properly to provide residents with consistent access to hot water for bathing and personal hygiene. Multiple residents reported receiving cold showers or being unable to bathe because the water was not hot. Resident 220 stated the facility ran out of hot water in the mornings because the kitchen used all the hot water, and said she had been showering early to avoid cold water. Resident 171 reported refusing showers on two days because the water was cold and said staff filled bowls with water for bed baths and heated the water in the microwave. Resident 273 stated she had not showered in three weeks because the water was cold and described one shower as so cold that she screamed. Staff also confirmed problems with hot water availability. A CNA stated shower water was sometimes cold because the kitchen used a large amount of hot water and that the water became cold after noon. Another CNA stated there was no hot water in a resident room sink and that she had experienced the lack of hot water twice in the past month in all rooms, requiring her to warm water from another sink or microwave it for resident care. The Maintenance Supervisor stated he had received complaints from CNAs about shower water not getting hot, that the boiler was not working on 4/7/2026 and was repaired that morning, and that he had previously installed a circulation pump because some nursing stations did not have regular hot water. The DON stated it was not appropriate for residents to bathe in cold water and that microwaving water for bathing was unacceptable because staff could not accurately determine the temperature.
Incorrect Room Clocks and Inconsistent Hot Water
Penalty
Summary
The facility failed to maintain a safe and homelike environment for residents by not ensuring room clocks displayed the correct time and by not consistently providing hot water for resident care. The report identified that the clocks in the rooms of three residents were not showing the correct time, including one clock observed displaying 5 p.m. when the actual time was 9:35 a.m. Staff stated the clocks were not working and needed repair, and one resident stated the incorrect time could cause confusion. The maintenance supervisor stated staff and anyone entering the rooms could report malfunctioning clocks, and that maintenance also conducted room rounds to check supplies and equipment. The report also described repeated problems with hot water availability in resident rooms and shower areas. One resident with diabetes, hemiplegia, and hemiparesis stated the bathroom sink did not produce hot water, and a CNA stated this had been an ongoing problem and that cold water was often microwaved before care was provided. Another CNA stated she could not clean a resident’s hair because there was no hot water from the sink, and said the problem had occurred in multiple rooms. The maintenance supervisor stated he had received almost daily complaints from CNAs that the water boiler was not producing hot water and that it took 45 seconds to one minute for water to become hot. Several residents reported that shower water was cold or that they avoided showering because of it. One resident with UTI, polyneuropathy, DM, and chronic pain said she refused showers on two days because the water was cold and that staff heated water in bowls using a microwave for bed baths. Another resident with gout, polyneuropathy, chronic viral hepatitis C, and joint pain said she had to shower early in the morning to avoid cold water. A third resident with quadriplegia, dermatitis, PVD, and anemia stated she had not showered in three weeks because the water was cold and described one shower as so cold that she screamed. CNAs stated shower water could become cold later in the day, and the maintenance supervisor stated the boiler had not been working properly and was repaired after a heating repair company identified and replaced failed parts.
Infection Control Lapses During Vital Signs, Meal Service, and Resident Care
Penalty
Summary
The facility failed to ensure infection control practices were followed during care for a resident who was admitted with anemia, hypertension, and dementia and was documented as alert, oriented, and cognitively intact. During a 9:28 a.m. observation in the resident’s room, an LVN removed an automated blood pressure cuff from the medication cart and took the resident’s blood pressure after the machine displayed an error message. The LVN did not perform hand hygiene or sanitize the blood pressure cuff before or after using it on the resident. During a second observation at 9:40 a.m. in the same resident’s room, the same LVN removed a manual blood pressure cuff and stethoscope from the medication cart and retook the resident’s blood pressure. The LVN again did not perform hand hygiene or sanitize the blood pressure cuff or stethoscope before or after the procedure. After completing the task, the LVN placed the equipment on top of the medication cart and still did not perform hand hygiene. The LVN stated he forgot to clean the equipment and did not perform hand hygiene because he was nervous, and stated he should have done so before taking the resident’s blood pressure. The facility also failed to ensure hand hygiene was performed during meal service and resident care. During lunch tray distribution in the main dining room, an Activities Assistant handled a pen, wrote on meal tickets, opened residents’ milk and other items, and served multiple trays without performing hand hygiene. In another observation, a CNA entered a resident’s room carrying a bag with a gown and towel, placed the bag on a table without hand hygiene, retrieved a blood pressure machine from the hallway, and entered the room to take vital signs without hand hygiene. The CNA then moved toward the next bed to take another blood pressure reading. The IP, DON, and staff interviews confirmed that hand hygiene and disinfection of reusable equipment were expected before and after resident contact and between residents.
Failure to Maintain Resident Privacy and Dignity During Care and in Hallway
Penalty
Summary
The facility failed to ensure Resident 256’s privacy and dignity were maintained during care and while in common areas. Resident 256 was admitted with diagnoses including Parkinson’s disease and atrial fibrillation, had limited decision-making capacity, and was dependent for care, including eating, toileting, and showering. During observation on 4/8/2026, an LVN administered medication while the resident’s privacy curtain remained open from the hallway, leaving the resident’s legs and foley catheter tubing visible. The LVN stated staff should close the privacy curtain during care to maintain privacy and dignity and that leaving it open could make the resident feel exposed, uncomfortable, and embarrassed. During a later observation on 4/9/2026, the resident was seen sitting in a wheelchair in the hallway with legs exposed and foley catheter tubing visible while accompanied by an OTA. The OTA stated the resident’s dignity was not maintained and that staff should have intervened immediately to cover the resident and reposition the tubing. The SNE stated facility policy requires staff to maintain residents’ dignity at all times, including closing privacy curtains or doors during care, keeping residents properly covered, and ensuring medical devices such as foley catheters are not exposed in public areas. Facility policies on catheter care, dignity, and resident rights also stated that privacy must be provided and resident privacy and dignity protected.
Call Lights Out of Reach and Bed Too Short for Resident
Penalty
Summary
The facility failed to ensure call lights were within reach for three sampled residents. Resident 241, who was admitted with diagnoses including overactive bladder, paraplegia, and anxiety disorder, was cognitively intact and dependent with ADLs. During observation, Resident 241 was lying awake in bed, calling for help and asking to be pulled up in bed, but the call light was tied to the back of the bed rail and out of reach. Resident 241 stated she needed help and could not find the call light, and LVN 3 confirmed the call light was not within reach and that the resident was unable to press it. Resident 193, admitted with diagnoses including cachexia, dysphagia, and left-hand contracture, had severely impaired cognition and was dependent with ADLs. Resident 120, admitted with diagnoses including functional quadriplegia, adult failure to thrive, and dysphagia, had moderately impaired cognition and was dependent with ADLs. During observation, the call lights for Residents 193 and 120 were not within their reach. CNA 6 stated she forgot to check the call light during her rounds at the end of her shift, and the DON stated the call light was the resident's first means of communication and that all staff were expected to ensure call lights were within reach. The facility also failed to provide a safe and appropriate bed frame for Resident 58. Resident 58 was admitted with diagnoses including diabetes mellitus and spinal stenosis, had intact cognition, and required maximal assistance with toileting, showering, bathing, and personal hygiene. Resident 58 stated his bed was too short and that he had told staff, but nothing was done. During observation, his feet were pressed against the foot of the bed on the bed board. CNA 5 stated the bed appeared too short for him because he is a tall man, and the DON stated Resident 58 should have a longer bed so he is comfortable because his feet should not be touching the bed board.
Inaccurate MDS Coding for a Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the care and services provided for one resident. The resident was admitted and later readmitted to the facility, and the admission record listed diagnoses of diabetes mellitus and dementia. In the MDS dated [DATE], the resident was coded as having severely impaired cognition and as being dependent for activities of daily living. During a concurrent interview and record review, the MDS nurse stated the resident was not currently on any anticoagulants and acknowledged that the resident’s MDS was inaccurate. The MDS nurse stated it was important for the MDS to be coded correctly because it reflects the assessment and care plan for the resident. The DON also stated that the MDS must be completed accurately because it reflects the resident’s condition in real time. The facility policy titled Resident Assessment Instrument (RAI) Process stated that the purpose of the policy is to ensure accurate and timely assessments reflecting residents’ needs and support appropriate care planning.
Failure to Provide Timely Incontinent Care and Bed Bath
Penalty
Summary
The facility failed to provide a bed bath and incontinent pad change for a resident who was unable to perform activities of daily living independently. The resident’s record showed diagnoses including type 2 diabetes with hyperglycemia, long-term insulin use, and hyperlipidemia. The MDS dated 1/2/2026 indicated the resident had mild cognitive skills for daily decision making and was dependent for bed mobility, oral hygiene, toileting hygiene, personal hygiene, showering, and upper and lower body dressing. The history and physical noted fluctuating capacity due to cognitive impairment, and the care plan stated the resident was totally dependent on toileting and incontinent care and preferred bed baths. During observation on 4/7/26, the resident was lying in bed, stated she was itching, and said she had not been changed since the morning. She reported that she had used the call light and that CNA 1 answered at 11:20 a.m. and said CNA 2 would come in about 10 minutes to change her. At 11:58 a.m., the resident was still in a wet incontinent pad, was significantly itching, and appeared emotional while scratching her skin. The resident stated the last perineal care had occurred at 4:30 a.m. and that no additional care had been provided since then. LVN 2 stated CNA 2 had provided personal care to the resident’s roommate earlier that morning but did not change this resident’s incontinent pad. CNA 2 stated she went on break at 11:45 a.m. and had not changed the resident, and she said she was unable to do so alone and did not request help from coworkers. CNA 1 stated she answered the resident’s call light, told the resident she would check with CNA 2 and return in about 10 minutes, but did not provide the needed assistance or communicate the resident’s need for incontinent care to another CNA. The facility policy stated staff will ensure ADLs are monitored, assisted with, and provided to residents who are unable to perform them.
Missed Ordered Medications for a Resident
Penalty
Summary
The facility failed to ensure Resident 242 received ferrous sulfate and carvedilol as prescribed. During an observation in the resident’s room, LVN 4 was seen preparing and administering the resident’s 9:00 a.m. medications, but did not prepare or administer the ordered ferrous sulfate or carvedilol. The carvedilol was not given because the medication was not available. Resident 242’s record showed diagnoses including anemia, HTN, and dementia. The resident’s H&P dated 3/1/2026 indicated the resident was alert and oriented, and the MDS dated 1/1/2026 indicated cognition was intact and the resident was dependent with ADLs. The order summary report dated 4/9/2026 showed an order for ferrous sulfate 325 mg by mouth at 9:00 a.m. for anemia and carvedilol 25 mg twice daily for HTN, with hold parameters for SBP less than 110 and HR less than 60. During interview, LVN 4 stated the ferrous sulfate was missed because the order was not seen on the computer screen, and carvedilol was not administered because it was unavailable. The DON stated medications should be administered as prescribed and must be available for nurses to give.
Medication pass error rate exceeded threshold after missed ordered doses
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent during medication pass for one of seven sampled residents, Resident 242. During observation, interview, and record review, Resident 242 was found to have missed doses of ferrous sulfate and carvedilol that were ordered by the physician. The record showed Resident 242 was admitted and readmitted to the facility with diagnoses including anemia, hypertension, and dementia, and the H&P dated 3/1/2026 indicated the resident was alert and oriented. The MDS dated 1/1/2026 indicated cognition was intact and the resident was dependent with ADLs. The order summary report dated 4/9/2026 showed an order for ferrous sulfate 325 mg by mouth at 9:00 a.m. for anemia and carvedilol 25 mg twice daily for hypertension, with parameters to hold for SBP less than 110 and HR less than 60. During interview, LVN 4 stated ferrous sulfate was missed because the order was not seen on the computer screen, and carvedilol was not given because the medication was unavailable. LVN 4 stated the missed medications placed Resident 242 at risk for stroke or heart attack. The DON stated medications should be administered as prescribed and must be available for nurses to give, and that failure to administer them as ordered would delay treatment and could result in high blood pressure.
Expired Medications and Unreplaced Emergency Insulin Kit
Penalty
Summary
Medication storage was not maintained in accordance with facility policy and manufacturer expiration dates. During observation in one medication room, a container of Gavilyte-G solution was found with an expiration date of 6/16/2025. During a later observation in another medication room, two expired pneumococcal vaccines and two expired COVID-19 vaccines were found, along with an open insulin e-kit that had last been accessed on 11/16/2025. The RN Supervisor, LVN, and DON each stated that expired medications should not be kept for resident use and that the insulin e-kit should have been reordered when it was opened so emergency medications would be available. Review of the facility’s Medication Ordering and Receiving policy stated that emergency kit use is to be recorded and replacement requested as soon as possible after administration, and that kits are inventoried at least every 30 days for completeness and expiration dating. Review of the Medication Storage policy stated that no expired medication will be administered to a resident and that all expired medications will be removed from active supply and destroyed in the facility. The observations showed expired medications and vaccines remained in the medication rooms, and the insulin e-kit had not been replaced after opening.
Failure to Follow Up on Dental Services for a Resident with Tooth Infection
Penalty
Summary
The facility failed to provide dental services for one sampled resident, Resident 198. The resident was admitted with diagnoses including major depressive disorder and hypertension. A dental consult note dated 2/11/2026 documented tooth pain and an infected tooth, and the resident agreed to a tooth extraction. The MDS dated 2/13/2026 showed the resident had moderately impaired cognition and required maximal assistance with toileting, showering, and personal hygiene. During an interview on 4/7/2026, Resident 198 stated she had been waiting to be seen by a dentist after a recent tooth infection and was still having pain. On 4/10/2026, the SSD stated the resident's last dental visit was 2/11/2026 and that the recommendation for tooth extractions due to infections and a fistula was not followed up on, although it should have been. The DON stated the social services department was expected to follow up with dental recommendations, and the facility policy stated routine and emergency dental services are available and social services representatives will assist residents with appointments.
Late Lunch Tray Delivery
Penalty
Summary
Meals were not served in a timely manner for two sampled residents, Resident 24 and Resident 5, when their lunch trays were delivered more than one hour late. Resident 24 had diagnoses including DM, hypokalemia, gastro-esophageal reflux, and chronic kidney disease, and her H&P indicated she had the capacity to understand and make decisions. Her MDS showed she was independent with eating but needed set up or clean-up assistance with oral hygiene and partial to moderate assistance with toileting, showering, dressing, and personal hygiene. Resident 5 had diagnoses including ESRD, dependence on renal dialysis, DM, and anemia. His MDS indicated he was dependent on nursing staff for eating, oral hygiene, toileting, showering, dressing, and transferring, and his H&P stated he did not have the capacity to understand and make decisions. During observation, residents were seated in the dining room waiting for lunch while the posted mealtime was 11:45 a.m.; Resident 24 was served at 1:00 p.m. and Resident 5 at 1:11 p.m. CNA 9 stated residents usually eat at about 12 p.m. and did not know why the trays were late, and the DON stated meal trays should be delivered on time because residents become hungry between meals. The facility policy stated food will be delivered promptly and meals will be distributed promptly with supervision as needed.
Unsafe Food Storage, Thawing, and Cold Holding Practices
Penalty
Summary
The facility failed to store and thaw food items safely in the kitchen. During an observation on 4/7/2026 at 8:10 a.m., an open container of garlic powder, corn starch, kosher salt, and macaroni was observed without open dates. In the same observation, frozen chicken was being defrosted in the sink in a container of stagnant water. During an interview on 4/10/2026 at 9:47 a.m., the Cook stated that any time a food item is open, an open date must be placed on the package, and that when defrosting meat, it must be fully submerged in a basin of cold running water. During an observation on 4/9/2026 at 7:02 a.m. in the kitchen during breakfast tray line, the temperature of the milk was observed to be 55 F. During an interview on 4/10/2026 at 4:10 p.m., the Dietary Supervisor stated that when food is opened, staff must place an open date on the container, that frozen meat may be defrosted in the refrigerator or in a vessel with cold running water, and that milk must be served at 40 F or lower. The facility's policy and procedure titled General Food Preparation and Handling dated 3/8/2021 indicated that meats, fish, and poultry will be defrosted using safe thawing practices, and the policy titled Food temperatures indicated that all cold food items must be stored at 41 F or below and held below 41 F during the holding and plating process.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate and complete medication documentation for two sampled residents. For Resident 242, the MAR documented ferrous sulfate was administered on 4/10/2026 at 10:03 a.m., but during a medication pass observation on 4/8/2026 at 9:28 a.m., LVN 4 was observed preparing and administering the resident’s 9:00 a.m. medications and did not prepare or administer the ordered iron medication. Resident 242’s record showed diagnoses including anemia, hypertension, and dementia, and the resident was described in the H&P as alert and oriented and in the MDS as cognitively intact and dependent with ADLs. For Resident 214, the MAR documented administration of a COVID-19 vaccine and a pneumonia vaccine on 3/12/2026 at 11:29 p.m., but both vaccines were later observed in the medication refrigerator on 4/7/2026 during a concurrent observation and interview with LVN 5. Resident 214’s record showed diagnoses including diabetes mellitus, Alzheimer’s disease, and muscle weakness. The H&P described the resident as alert and oriented to name only, while the MDS indicated cognition was intact and the resident was dependent with ADLs. During interview, LVN 4 stated he missed giving the iron because he did not see the order on the computer screen and had already signed for the medication. LVN 6 stated she signs Resident 214’s MAR before actually giving medications and that she did not give the vaccines but documented them in error. The DON stated medications should be administered as prescribed and documented after preparation and administration, and that vaccines are preventive and residents who do not receive them as ordered are at risk for infection.
Hospice Care Plan Not Coordinated and Eligibility Not Reassessed
Penalty
Summary
Failure to ensure coordinated and comprehensive hospice services occurred for one of three sampled residents, a resident with DM and dementia who was admitted and later readmitted to the facility. The resident had an order for hospice services dated 6/19/2025 for protein calorie malnutrition, and the MDS indicated severely impaired cognition and dependence for ADLs. During interview and record review, RNS 2 stated the hospice plan of care had not been merged with the facility care plan, and MDSN 1 stated the facility did not have an individualized hospice care plan that reflected the hospice services, although one should have been in place. The DON stated that for residents on hospice, the facility and hospice staff collaborate on care and that this collaboration should be reflected in the resident's care plan. The facility also did not ensure the resident's hospice eligibility was reassessed after clinical improvement. RNS 2 stated the resident had been placed on hospice because she was terminally ill with severe protein malnutrition, but also stated she did not consider severe protein malnutrition to be a terminal diagnosis. The hospice nurse reportedly told RNS 2 that a low albumin level was the determining factor for keeping the resident on hospice. However, the resident's nutrition records showed she had been eating between 26% and 100% of meals, and the hospice doctor stated the resident's decline had slowed, her recent albumin level was not severe, her weight loss had slowed, and she had been eating, with the hospice team planning to discuss removing her from hospice. Wound documentation also showed improvement, including smaller right hip and sacrococcygeal wounds and a resolved abdominal wound.
Failure to Collect Ordered Labs and Notify Physician When Tests Not Performed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered laboratory tests were collected in a timely manner and that physicians were notified when those tests were not performed for two residents. For one resident admitted with COPD, HTN, and hyperlipidemia, with moderate cognitive impairment but largely independent in ADLs, a respiratory infection screener documented a new or increased cough and loss of appetite. A change in condition evaluation on the same day showed a new physician order for a respiratory panel. However, the respiratory panel order dated that day was not carried out, and there was no follow-up to ensure the specimen was collected. For the second resident, admitted with hypertensive heart disease with heart failure, hypothyroidism, atrial fibrillation, and a history of COVID-19, and documented as having severe cognitive impairment and needing extensive assistance with ADLs, a change in condition note recorded two episodes of diarrhea, with the physician and responsible party notified. Later that day, another change in condition note documented nausea and two episodes of vomiting. A physician order was then written for a one-time morning BMP. Review of the laboratory log showed no phlebotomist signature for this BMP order, indicating the specimen was not collected as ordered. Record reviews and interviews with the Infection Prevention Nurse showed that for both residents there was no documentation in change in condition follow-up notes or progress notes that the ordered labs were followed up for collection or that the physician was notified when the respiratory panel and BMP were not obtained. The IPN, DON, and ADON each stated the importance of collecting these labs and notifying the physician when they were not collected, but the facility’s written policy on lab and diagnostic test results did not include procedures for following up on whether tests were collected or sent to the lab, nor did it specify procedures for notifying the physician when a lab or diagnostic test was not collected or performed.
Failure to Ensure Resident Dignity and Safe Handling During Personal Care
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) failed to treat a resident with dignity and respect during personal care, resulting in rough handling. The resident, who had a history of multiple rib fractures and a previous left arm injury from a car accident, required full assistance with toileting and personal hygiene. On the day of the incident, the CNA appeared rushed and in a bad mood, reportedly due to working a double shift. The resident expressed a preference for showering later in the day, but the CNA insisted on providing a morning shower and responded curtly when informed of the resident's preference. After the shower, the CNA left the resident in a wheelchair for about 30 minutes and did not return to clean the bedside area. Later that evening, while assisting the resident with putting on a gown, the CNA squeezed the resident's left hand very hard, despite being told to be careful due to the resident's prior injury. The resident reported feeling that the CNA was handling her too roughly and expressed concern during care, but the CNA did not respond and continued with the task. The following day, the resident noticed a purplish discoloration on her left thumb and reported it to a licensed vocational nurse (LVN), stating that the injury likely occurred when the CNA squeezed her hand. Interviews with staff and another resident corroborated the account of rough handling and emotional distress. The LVN and unit director of nursing (UDON) observed the discoloration and found the resident's report credible, noting that the injury was consistent with the described incident. Facility policy requires all residents to be treated with kindness, respect, and dignity, which was not upheld in this case.
Failure to Timely Report Suspected Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting a suspected abuse incident to the State Survey Agency within the required two-hour timeframe after the allegation was made. A resident with moderate cognitive impairment and multiple medical conditions, including acute kidney failure and chronic heart failure, was reportedly handled roughly by a male CNA during a night shift. The resident's responsible party informed an LVN of the incident, but the LVN did not notify the RN Supervisor or the abuse coordinator as required by facility policy and instead advised the responsible party to follow up with management on the next business day. Multiple staff interviews confirmed that the allegation of rough handling was communicated to the LVN on the day it was reported, but the LVN did not escalate the report immediately. Other staff, including another CNA and RN, stated that such allegations should be reported to the abuse coordinator and investigated without delay, regardless of the time or day. The facility's policy clearly states that all allegations of abuse, neglect, or mistreatment must be reported immediately, but not later than two hours after the allegation is made, to the appropriate authorities. The delay in reporting resulted in the abuse allegation not being communicated to the State Survey Agency, ombudsman, and law enforcement within the required timeframe. The administrator only became aware of the incident the following day and subsequently reported it approximately six hours after being informed. This failure to follow established reporting procedures placed residents at risk for potential continued abuse and delayed investigation.
Failure to Reconcile Discharge Orders Leads to Baclofen Toxicity and Immediate Jeopardy
Penalty
Summary
A deficiency occurred when a registered nurse failed to properly review and reconcile conflicting hospital discharge instructions for a resident who had end-stage renal disease and was dependent on hemodialysis. The discharge documents from the general acute care hospital contained contradictory orders: one stated that Baclofen should not be used due to causing confusion, while another listed Baclofen as a medication to continue. The nurse did not review the entire set of discharge instructions for accuracy, nor did she clarify the conflicting orders with the resident's physician before transcribing and administering Baclofen. As a result, the nurse administered multiple doses of Baclofen to the resident without physician verification, contrary to the facility's policy requiring such verification for hospital transfer orders. There was no documentation indicating that the nurse contacted the attending physician to resolve the discrepancy. The resident subsequently experienced shortness of breath, elevated blood pressure, generalized weakness, and increased confusion, which led to a change of condition and transfer to the hospital. At the hospital, the resident was diagnosed with acute toxic encephalopathy due to Baclofen toxicity and required hemodialysis. Interviews with facility staff, the resident's family, and medical professionals confirmed that the medication error was due to the failure to reconcile and verify the discharge orders, and that the facility's policy and standard admission process were not followed. The incident resulted in an Immediate Jeopardy situation due to the serious harm caused to the resident.
Removal Plan
- The admitting nurse verified the admissions orders with the attending physician.
- A medication error report for Baclofen was completed and reported to the attending physician and Resident 10's family.
- The Interim Chief Clinical Officer (CCO)/Designee provided a 1:1 in-service training to RN 1 on reviewing discharge orders, reconciling and verifying orders with attending physicians prior to carrying out the orders, and the facility's policy requiring verification of GACH orders with the attending physician before medications are transcribed for administration.
- A random audit of all in-house patients was completed by the Health Information Manager (HIM) and the Interim CCO/designee.
- All residents receiving Baclofen were identified and reviewed.
- A random audit of all newly admitted residents was conducted by the HIM and Interim CCO/designee.
- All identified residents' physician orders were reviewed and reconciled with their attending physicians.
- The Director of Staff Development (DSD)/Clinical Trainer provided re-training to licensed nurses on entering orders into the Electronic Treatment Administration Record (eMAR/eTAR) prior to/pending confirmation, reconciliation, and verification of orders.
- Licensed nurses on leave, vacation, out sick, or newly hired will be educated prior to the start of their shift.
- The DSD and Clinical Trainer conducted in-service training for licensed nursing staff on the facility's policy requiring verification of GACH orders with the attending physician before medications are transcribed for administration.
- Training will continue until all licensed nursing staff have attended.
- Nurses on leave, vacation, out sick, or newly hired will be educated prior to the start of their shift.
- A root cause analysis (RCA) was conducted, revealing multiple system-level factors contributing to the medication reconciliation error, including knowledge gaps, inconsistent policy application, lack of structured admission process, and limited leadership oversight.
- A multidisciplinary team (Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, Regulatory Compliance Nurse) was assigned specific roles to monitor, oversee, and implement corrective actions, conduct audits, provide ongoing training, update policies, and ensure compliance and quality improvement.
Failure to Honor Resident's Bathing Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's expressed preference for showers over bed baths. The resident, who was admitted following a left leg below-the-knee amputation and required assistance with activities of daily living, was documented as being able to make reasonable and consistent decisions. The Minimum Data Set indicated that it was very important for the resident to choose between a bed bath or a shower. However, documentation showed that during a specified period, the resident received only two showers, refused a bath six times, and had fifteen shifts with no documentation of bathing care provided. The resident reported that, despite requesting showers, he was often given bed baths instead, and sometimes refused care when staff insisted on a bed bath. After a COVID-19 diagnosis, the resident refused a shower due to not feeling well, but also stated that his requests for showers were not accommodated during his recovery. Interviews with staff confirmed that the resident was particular about his care, especially regarding showers, and that residents should be able to make decisions about their care. Facility leadership acknowledged the importance of honoring resident preferences to ensure comfort and satisfaction. The facility's policy on dignity and quality of life emphasized providing care in a manner that respects resident rights and preferences, but this was not consistently followed in the resident's case.
Failure to Implement Fall Management Program in High-Risk Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that included a Fall Management Program for a resident assessed as high risk for falls. The resident, who had a history of cerebral infarction resulting in left side hemiplegia and required assistance with activities of daily living, was identified as high risk for falls based on the Morse Fall Scale and interdisciplinary team assessments. Despite these findings, the care plan only included general interventions such as encouraging the resident to use the call light and attempting to anticipate needs, without incorporating the facility's established Fall Management Program. Interviews with facility leadership confirmed that the Falling Star Program, which includes specific interventions like a low bed, fall pad, colored wristband, and star magnet, should have been included in the care plan for residents at high risk for falls. Review of facility policies indicated that such interventions are required for residents with high fall risk, but documentation showed these were not implemented for the resident in question. This omission resulted in the resident's care needs not being thoroughly addressed.
Failure to Implement QAPI Following Medication Error
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) plan after being made aware of a medication error involving a resident who was admitted from a general acute care hospital. The registered nurse did not thoroughly review or clarify conflicting discharge instructions regarding the administration of Baclofen, a medication known to cause confusion, before transcribing and administering it. Specifically, the nurse did not verify the hospital's orders with the attending physician, despite discrepancies in the discharge instructions—one indicating Baclofen should not be used due to confusion, and another listing it as a medication to continue. As a result, the resident received multiple doses of Baclofen without proper clarification. This error led to the resident experiencing shortness of breath, elevated blood pressure, generalized weakness, and increased confusion, ultimately resulting in a transfer back to the hospital where the resident was diagnosed with acute toxic encephalopathy and required dialysis. Interviews with facility leadership revealed that no incident report was filed, and no QAPI meeting was conducted to address the medication error, investigate the root cause, or implement corrective actions as required by the facility's own policies and procedures.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented for affected residents. The report highlights lapses in the facility's pressure ulcer prevention and care protocols, resulting in inadequate care for residents at risk or with existing pressure ulcers.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care practices for residents requiring assistance with bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
A facility failed to prevent the development of an avoidable, facility-acquired, unstageable pressure injury in a resident who was admitted with intact skin on the sacrococcyx area. The resident, who had a history of post laminectomy syndrome, spinal cord disease, kidney cancer, and bone tumor, was dependent on staff for toileting and bathing and required assistance for turning and repositioning. Despite physician orders and facility policy requiring repositioning every two hours, documentation showed multiple shifts where the resident was not turned or repositioned as required. The resident's care plan and physician orders specified the need for turning and repositioning every two hours, as well as regular checks for incontinence. However, facility records indicated that on at least fourteen occasions, staff failed to turn and reposition the resident during entire shifts. There was no documentation explaining these omissions, nor was there evidence that staff updated the care plan or documented any refusals of care by the resident, as required by facility policy. Interviews with staff revealed that some believed the resident refused to be woken for repositioning, but this was not communicated to nursing staff or documented in the medical record. As a result of these failures, the resident developed a stage 2 pressure injury on the sacrococcyx, which deteriorated to an unstageable wound and ultimately to a stage 4 pressure injury after debridement at an acute care hospital. The wound became infected, delaying further medical treatment for the resident's underlying conditions. Family members reported that staff did not consistently reposition the resident or provide necessary padding when the resident was in a wheelchair, and that the resident required assistance and reminders to change position due to loss of sensation in the lower body.
Failure to Develop and Implement Comprehensive Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address offloading and pressure relief for a resident who was at risk for pressure injuries while sitting in a wheelchair. Upon admission, the resident had no pressure injuries to the sacrococcyx area and was admitted with multiple diagnoses, including post laminectomy syndrome, spinal cord disease, and cancer. The resident was dependent on staff for toileting and bathing and required assistance for mobility, with no feeling in the lower body due to spinal surgery. Over the course of the resident's stay, documentation showed the development and deterioration of a pressure injury on the sacrococcyx area, progressing from no injury to a stage two, and eventually to an unstageable pressure injury. Interviews with staff and family revealed that the resident frequently sat in a wheelchair for extended periods while visiting with family, sometimes without appropriate padding or repositioning. Staff confirmed that there were no specific care plan interventions or physician orders in place to address offloading or pressure relief while the resident was in the wheelchair, despite the resident's inability to reposition independently. The Director of Nursing acknowledged that the care plan did not include interventions for offloading pressure while the resident was in bed or in the wheelchair, and that care plans are essential for guiding care and preventing further skin breakdown. The facility's policy required care plans to be updated to reflect current interventions, but this was not done in the resident's case, contributing to the progression of the pressure injury.
Delay in Initiation of PT/OT Services Due to Authorization Lapse
Penalty
Summary
A deficiency occurred when a resident with impaired mobility and diagnoses of muscle wasting, atrophy, and muscle weakness was not provided with timely physical therapy (PT) and occupational therapy (OT) services as ordered by their physician. The resident required moderate assistance with activities of daily living, including toileting, bathing, dressing, and transfers, and used a manual wheelchair. The Minimum Data Set (MDS) confirmed the resident's intact cognition and functional limitations. The physician's order for PT and OT services was placed, but there was a 30-day delay before the therapies were initiated. The delay was attributed to the rehabilitation department not following up on the required authorization for therapy services. The Director of Rehabilitation (DOR) acknowledged responsibility for tracking and following up on therapy orders and authorizations but did not act until a month after the initial order. The Clinical Chief Officer (CCO) confirmed that the facility's process requires the rehabilitation department to ensure timely authorization and implementation of therapy orders, which typically should not exceed one week. Facility policy and procedure documents reviewed indicated that the DOR is responsible for tracking residents' therapy needs and ensuring timely and accurate clinical documentation. The policies also outlined the responsibilities of the supervising occupational therapist to confirm and implement therapy orders, consult with physicians, and coordinate care. Despite these policies, the resident's therapy services were delayed, resulting in a 30-day gap between the order and the initiation of PT and OT evaluations and treatments.
Failure to Doff PPE and Perform Hand Hygiene Exiting EBP Room
Penalty
Summary
Restorative Nurse Assistant 1 (RNA 1) failed to properly remove personal protective equipment (PPE) and perform hand hygiene when exiting the room of a resident who was on Enhanced Barrier Precautions (EBP). The resident in question had multiple diagnoses, including end-stage renal disease, dependence on dialysis, type 2 diabetes, and pressure ulcers, and was on EBP due to the presence of a dialysis port and a recent lower extremity amputation. Facility policy and posted signage required staff to don PPE before entering and doff PPE and perform hand hygiene before exiting the resident's room. On the day of the incident, RNA 1 was observed exiting the resident's room wearing gloves and a gown, walking into the hallway to retrieve an oxygen tank, and then re-entering the room without removing PPE or performing hand hygiene. This action was contrary to the facility's infection prevention and control policy, which was confirmed by interviews with the Registered Nurse Supervisor, Director of Quality Assurance, and Chief Clinical Officer. All confirmed that PPE should be removed and hand hygiene performed prior to leaving the resident's room to prevent the spread of infection. RNA 1 acknowledged during an interview that she failed to remove her PPE and perform hand hygiene before exiting the room, stating she was focused on retrieving the oxygen tank and did not realize her mistake until after the fact. The facility's policy, as reviewed, clearly outlined the steps for PPE use and removal in accordance with EBP and standard precautions, emphasizing the importance of these measures in preventing cross-contamination and the spread of multidrug-resistant organisms.
Failure to Secure Rehab Equipment Leads to Resident-to-Resident Assaults
Penalty
Summary
The facility failed to ensure that the rehabilitation (Rehab) room and its equipment were secured and supervised at all times, resulting in unauthorized access by residents. Specifically, a resident with a history of anxiety disorder, cognitive decline following a stroke, and intact cognition according to the Minimum Data Set (MDS), was able to enter the Rehab room without staff knowledge and obtain a dowel, a piece of equipment used for physical therapy. The Rehab room door was routinely closed but not locked when staff were not present, and weighted dowels and free weights were left unsecured and accessible on the wall. This lack of supervision and security allowed the resident to use the dowel to physically assault two other residents on separate occasions. In one incident, a resident was struck on the left arm, and in another, a resident was hit on the right arm, right shoulder, and face, then pushed to the floor, resulting in a non-displaced fracture of the mid sacrum. Staff interviews and progress notes confirmed that the dowel used in the assaults was taken from the Rehab room, and that staff were unaware of the resident's access to the equipment until after the incidents occurred. Observations conducted nearly three weeks after the second incident revealed that the Rehab room equipment remained unsecured. The facility's policy required individualized safety assessments and targeted interventions to reduce accident hazards, including appropriate supervision based on residents' needs and environmental risks. However, the interdisciplinary care team did not identify or address the risk of residents accessing Rehab equipment unsupervised, nor did they implement interventions to prevent such access. The failure to secure the Rehab room and its equipment, combined with insufficient supervision and lack of timely care plan updates, directly led to the incidents of resident-to-resident physical aggression and injury.
Removal Plan
- Resident 1 and Resident 3's incident was reported to the California Department of Public Health (CDPH) with final investigation completed and submitted. Resident 1 and Resident 3 were immediately separated from each other.
- Resident 3 was transferred to another room in a different wing with ongoing monitoring by staff of Resident 3's psychosocial wellbeing. Resident 3 was transferred to the hospital for assessment and returned the same day. Resident 3's care plan was updated to include a resident-to-resident altercation.
- Resident 1's care plan for behaviors was reviewed and updated to include physical aggressive behavior. Resident 1 was referred to a psychiatric mental health Nurse Practitioner but refused. The IDT met with Resident 1 and her family to assist Resident 1 to be seen by a psychiatrist. Resident 1 was sent to GACH for in-patient psychiatric evaluation and returned with a UTI diagnosis and antibiotics. Resident 1's care plan and IDT note was updated to address Resident 1's use of a dowel during the episode of aggressive behavior.
- A tracking system was implemented requiring Rehab staff to sign weighted dowels, free weights, and ankle weights in and out, noting their location and assigned user. If any item is found missing, staff must immediately notify the Rehab Manager and complete an incident log to initiate a prompt search and resolution process.
- The Executive Director was assigned to the Rehab Manager to ensure that weighted dowels, free weights, and ankle weights were properly locked and secured at the end of each treatment day. A log was created to document and verify daily compliance with this security measure.
- The Executive Director designated the Rehab Manager to ensure that access to the Rehab room is secured when staff were not present to supervise the gym. A log was created to document daily compliance and serve as evidence of adherence to this protocol with rehab staff assigned with responsibility of documenting the time the room was secured and verification that no residents remain inside.
- The IDT was in-serviced by the Senior Nurse Executive to review how to conduct an IDT meeting when reviewing resident to resident incidents.
- An ad hoc QAPI Committee meeting was scheduled to conduct a root cause analysis to determine key issues stemming from the recent resident to resident altercation to determine process breakdowns, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions.
- The Executive Director will oversee corrective actions initiated and monthly thereafter during QAPI meetings, based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical record audits and safety equipment monitoring of rehab equipment random audits, will be reviewed and revised with the QAPI Committee.
- Any new issues found during medical record audits on resident to resident altercation will be presented to the IDT members for immediate action. The Chief Clinical Officer will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.
- Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, and Regulatory Compliance Nurse will perform specific roles in monitoring, oversight, education, compliance, and corrective action implementation.
- All residents were identified as potentially affected by the deficient practice.
- The Interdisciplinary Team (IDT) in-service by the Senior Nurse Executive to review how to conduct an interdisciplinary team meeting when reviewing resident to resident incidents.
- A log was created to document and verify daily compliance with securing weighted dowels, free weights, and ankle weights and locking the rehab room when no staff were present to supervise. The Activity Director and/or designee will use a monitoring tool to document compliance of logs created by the Rehab Department. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Issues found will be referred to the ED for further review and revision of the action plan and/or to determine any further training needed for staff involved.
- The Medical Records Department will use a monitoring tool to audit the documented IDT and care plan for change of conditions related to any resident-to-resident altercations. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Any issues found will be referred to the Chief Clinical Officer immediately for further review and revision of the action plan and/or to determine any further training needed for staff involved.
- Inservice training for staff license nurses was started on updating comprehensive care plans for residents that have been identified with physical aggression. The facility will continue training until all staff nurses have attended.
- Inservice training for IDT was started on updating comprehensive care plan and interdisciplinary team investigation and documentation for residents that have been identified with physical aggression and those with resident-to-resident altercations. Training will continue until all IDT members have attended.
- Inservice training for rehab staff was started on how to secure weighted dowels, free weights, and ankle weights and the rehab room door when no staff are present in the gym to supervise, as well as additional in-service initiated on how to track and sign equipment in and out, noting its location and assigned user. Training will continue until all Rehab staff have attended.
Failure to Secure Rehabilitation Equipment Leads to Resident-on-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse when a resident obtained a rehabilitation dowel without authorization and used it to physically assault two other residents. The dowel, a piece of equipment intended for therapy, was stored unsecured in the rehabilitation room, which was not consistently locked or supervised outside of therapy hours. Staff interviews and observations confirmed that dowels and other equipment were accessible on the wall, and the rehabilitation room door was only locked when staff left the facility for the day, not during all unsupervised periods. One resident, with a history of anxiety disorder and cognitive decline following a stroke but assessed as having intact cognition, accessed the unsecured dowel and used it to strike another resident on the left arm and, in a separate incident, to hit a different resident on the right arm, right shoulder, and face before pushing her to the floor. The assaulted resident, who had hemiplegia and hemiparesis following a stroke and used a walker for mobility, sustained a non-displaced fracture of the mid sacrum and required transfer to an acute care hospital for evaluation and pain management. Multiple staff and resident interviews corroborated the sequence of events, including the use of the dowel as a weapon and the lack of immediate staff intervention to prevent the assault. The facility did not follow its own policy and procedure regarding the prevention, reporting, and correction of abuse, neglect, and mistreatment. The investigation revealed that staff failed to secure the rehabilitation room and its equipment, did not prevent the resident from accessing the dowel, and did not implement interventions to address the resident's behavioral risks or prevent further incidents. The lack of supervision and security measures directly contributed to the occurrence of physical abuse and injury among residents.
Failure to Log and Investigate Grievance Regarding Resident Care
Penalty
Summary
The facility failed to properly log and investigate a grievance regarding the care of a resident, as per their established policy and procedures. The resident, who was admitted with chronic respiratory failure, tracheostomy status, and ventilator dependence, had severe cognitive impairment and was unable to communicate effectively. The resident's responsible party (RP) reported multiple complaints about the lack of Activities of Daily Living (ADL) care, such as bathing and toileting, which were not formally logged or investigated by the facility. The responsible party observed the resident in soiled briefs and ungroomed during visits and expressed concerns to a registered nurse (RN) on several occasions. Despite these complaints, the RN did not initiate the grievance process, mistakenly believing the issues were resolved after discussions with the responsible party. This oversight led to a lack of formal investigation and follow-up, potentially delaying necessary care and services for the resident. Interviews with facility staff, including the Social Services Director, Social Services Assistant, and the Administrator, revealed that the grievance process was not followed. The Social Services Assistant was not informed of the complaints, and the Administrator was unaware of the issues. The facility's policy requires grievances to be investigated and resolved promptly, but this was not adhered to, resulting in a violation of the resident's rights and a potential delay in care.
Failure to Include Responsible Party in Care Planning
Penalty
Summary
The facility failed to conduct timely Interdisciplinary Team (IDT) meetings for Resident 1, who was admitted with chronic respiratory failure, tracheostomy status, and ventilator dependence. The IDT meetings, which are crucial for planning and updating the resident's care, did not include Resident 1's Responsible Party (RP1) as per the facility's policy. Despite multiple hospitalizations and severe cognitive impairment of Resident 1, the last IDT meeting involving RP1 was held in September 2024, leaving RP1 without the opportunity to discuss specific concerns about Resident 1's care, including the management of multiple pressure ulcers. RP1 expressed dissatisfaction with the lack of involvement in the care planning process and reported that Resident 1's wounds seemed to worsen after each return from the hospital. The facility's Director of Quality Assurance confirmed that RP1 was not included in IDT meetings held in early 2025 and acknowledged the failure to ensure RP1's participation. The facility's policies require that the IDT, in conjunction with the resident and their family, develop and update a comprehensive care plan, especially after hospital readmissions. The lack of regular IDT meetings and RP1's exclusion from the process potentially delayed necessary care interventions for Resident 1.
Failure to Assess and Monitor Resident's Condition After Incident
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident, identified as Resident 1, after an incident involving a Restorative Nursing Assistant (RNA1). RNA1 accidentally dropped a water bottle on Resident 1's left foot, causing pain. Despite the incident, there was no documented Change of Condition (COC) assessment, and the physician and family were not notified. The RNA1 admitted to not reporting the incident to the charge nurse, which led to a lack of proper assessment and monitoring of the resident's condition. Resident 1, who had a history of chronic respiratory failure, diabetes mellitus with diabetic peripheral angiopathy, and peripheral vascular disease, experienced worsening pain, swelling, and drainage from the left big toe. Despite these symptoms, there was no reassessment or monitoring of the wound condition after the initial COC was identified. The Treatment Administration Record indicated a treatment plan for the wound, but weekly assessments were not conducted as required by the facility's policy. Interviews with various staff members, including a Licensed Vocational Nurse, Registered Nurse Supervisor, and Director of Quality Assurance, revealed that the facility did not adhere to its policies for wound care and documentation. The lack of proper documentation and assessment of the resident's condition after the incident with the water bottle and the subsequent infection of the left big toe highlighted deficiencies in the facility's care and monitoring processes.
Failure to Prevent and Treat Pressure Injury
Penalty
Summary
The facility failed to provide adequate care for a resident who developed a Stage II pressure injury on the sacrococcyx, which progressed to a Stage IV pressure injury. The resident, who was in a persistent vegetative state and dependent on staff for activities of daily living, was admitted with multiple diagnoses, including chronic respiratory failure and a gastrostomy tube. Despite being at high risk for pressure injuries, the facility did not ensure consistent treatment and monitoring of the resident's pressure injury. The facility did not follow the physician's orders for treating the Stage II pressure injury, as the treatment was discontinued without documentation or explanation. The resident did not receive the prescribed wound care from November 8 to November 21, and there was a lack of weekly assessments and documentation of the pressure injury's progression. The interdisciplinary team recommended a consultation with a registered dietician, but this was not completed in a timely manner, delaying potential nutritional interventions that could have supported wound healing. The facility's policy required weekly wound assessments and documentation, but these were not consistently performed. The lack of regular assessments and failure to follow care plans contributed to the deterioration of the resident's pressure injury. The Director of Nursing acknowledged the systemic issue of inadequate documentation and monitoring, which led to the avoidable progression of the pressure injury to Stage IV.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for a resident identified as high risk for falls and injuries. The deficiency involved a Certified Nurse Assistant (CNA 2) leaving the resident unsupervised in the bathroom, contrary to the facility's Fall Prevention and Management Program policy. This policy mandates that residents receive adequate supervision and assistive devices to prevent accidents. The resident, who had a history of falls and was diagnosed with osteoporosis and kyphosis, was left unattended, leading to a fall and subsequent injuries. The resident's care plan, which highlighted the risk for falls, required staff to anticipate and meet the resident's needs, including the use of a front wheel walker (FWW) as needed. Despite this, CNA 2 left the resident alone in the bathroom to assist another resident, resulting in the resident attempting to ambulate back to bed using the FWW. The resident lost balance while trying to kick the bathroom door shut, leading to a fall that caused multiple fractures. The resident was later transferred to a General Acute Care Hospital for evaluation and treatment. Interviews with facility staff, including CNA 2, a Licensed Vocational Nurse, a Registered Nurse, and the Director of Staff Development, confirmed that the resident was forgetful and required assistance with ambulation. They acknowledged that the fall was preventable if the resident had not been left unattended. The facility's policy emphasized the importance of providing an environment free from accident hazards and ensuring supervision to prevent avoidable accidents, which was not adhered to in this case.
Improper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation protocols, as observed during a survey. A bottle of Lysol bleach cleaner was improperly stored in the dry food storage area, posing a risk of chemical contamination. Additionally, the ice machine drain was found to have dirt and debris, which could lead to bacterial growth. The facility also failed to label prepared food items in the refrigerator with preparation and use-by dates, increasing the risk of serving expired food to residents. Furthermore, the freezer temperature logs were not consistently completed, which is crucial for ensuring food is stored at safe temperatures. Interviews with staff, including dietary aides and the dietary supervisor, confirmed these deficiencies. The staff acknowledged the potential risks associated with these practices, such as food spoilage and the possibility of residents consuming contaminated or expired food. The facility's policies and procedures, which require proper labeling, storage, and sanitation practices, were not followed, leading to these observed deficiencies.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to provide necessary care and services for two residents, Resident 22 and Resident 100, by not ensuring timely response to call lights. Resident 22, who had intact cognition and required substantial assistance due to conditions such as hemiplegia, diabetes, and heart failure, was left in pain without timely assistance. Despite pressing the call light and screaming for help, the resident's call was ignored by LVN 11, who was nearby but did not respond. It took over 25 minutes for a Restorative Nursing Assistant to attend to the resident, who was then given pain medication for severe pain. Resident 100, who had hemiplegia, dementia, and a contracture of the right elbow, was found with the call light clipped to the curtain, out of reach. This resident, who lacked the capacity to make decisions, was at risk of falls and accidents due to the inability to call for help. LVN 13 and CNA 6 acknowledged the improper placement of the call light, which should have been within the resident's reach to ensure safety and timely assistance. The facility's policy required call lights to be answered promptly and within reach of residents, yet these standards were not met, leading to potential risks for the residents involved. The Director of Staff Development and Chief Clinical Officer confirmed the importance of timely response to call lights to prevent unrelieved pain and delays in care, as outlined in the facility's policies.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 34.48% error rate during medication administration for four residents. Resident 129 did not receive the full dose of Amlodipine as the medication was not properly mixed with water before administration via gastrostomy tube, leaving residual medication in the cup. This oversight was acknowledged by the LVN responsible, who admitted to not following the facility's policy of mixing crushed medication with water and ensuring the full dose was administered. Resident 80's blood pressure was not reassessed before administering medication, despite having specific parameters for holding or administering blood pressure medications. The LVN relied on pre-recorded vital signs taken by a CNA earlier in the morning, which were not verified before medication administration. This practice was against the facility's policy, which requires the charge nurse to check vital signs prior to administering medications with specific parameters. Residents 12 and 230 experienced delays in receiving their medications, with administration times exceeding the facility's policy of a 60-minute window around the scheduled time. Resident 12's seizure and anticoagulant medications were administered significantly late, and the physician was not notified before the late administration. Similarly, Resident 230's Metoclopramide doses were consistently administered late, with the LVN citing workload as the reason for the delay. These actions were contrary to the facility's guidelines for timely medication administration.
Significant Medication Errors Due to Late Administration
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 12, was free from significant medication errors. The resident, who had a history of hemiplegia, cerebral palsy, and convulsions, was not administered their prescribed medications, including Phenytoin, Phenobarbital, and Heparin, at the scheduled times. The medications were given several hours late on multiple occasions, which was not in accordance with the physician's orders. On specific dates, the resident's medications were administered significantly later than the scheduled times. For instance, on one occasion, the morning dose of Phenytoin was given over three hours late, and the subsequent dose was administered less than four hours after the late morning dose. Similarly, Heparin, which was supposed to be administered every 12 hours, was given late and not in accordance with the prescribed schedule. The Licensed Vocational Nurse (LVN) responsible for administering the medications acknowledged the delay and admitted to not informing the physician about the late administration before proceeding. The facility's policy required medications to be administered within a one-hour window of the scheduled time, and any deviations should have been communicated to the physician for further instructions. However, the physician was only notified after the medications were administered late. The Registered Nurse (RN) confirmed that the late administration could lead to potential overdosing, especially with medications like Phenytoin and Heparin, which require precise timing to avoid adverse effects. The failure to adhere to the medication schedule and notify the physician in a timely manner constituted a significant medication error.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control practices in several instances, leading to potential cross-contamination and risk of infection among residents. For Residents 126 and 500, the facility did not ensure that oxygen tubing and bags were changed and labeled weekly. This oversight was confirmed by LVN 8, who acknowledged that the tubing and bags were not dated, making it unclear when they were last changed. The facility's policy requires these items to be changed weekly to prevent bacterial growth that could lead to respiratory infections. Resident 218's tube feeding and water bags were not labeled or dated, as observed by LVN 8. The facility's policy mandates that these bags be changed every 24 hours to prevent spoilage and potential stomach issues. Additionally, a licensed nurse failed to remove her PPE before exiting Resident 517's room, which could lead to contamination in the hallway. This was acknowledged by RN 3, who admitted the mistake and the potential for spreading infection. In another instance, CNA 4 did not follow proper procedures after finding feces on the floor in Resident 106's room. Instead of calling housekeeping immediately, CNA 4 attempted to clean the area with dry towels and forgot to place a sign to prevent others from stepping on the contaminated floor. Furthermore, a visitor in Resident 169's room was not wearing the required PPE despite the resident being on contact isolation for Candida Auris. LVN 12 noted the oversight and the need to inform the visitor about the necessary precautions.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance a resident's dignity and respect during meal assistance. Specifically, a Certified Nursing Assistant (CNA) was observed standing over a resident, identified as Resident 17, while assisting her with eating. This action was contrary to the facility's policy and procedure, which emphasized providing a dignified dining experience to promote residents' well-being and self-esteem. The resident, who had severe cognitive impairments and required substantial assistance with eating, was not provided with the appropriate level of care that aligned with her care plan, which specified one-on-one assistance during meals. Interviews with various staff members, including other CNAs and the Director of Staff Development, confirmed that the proper procedure for feeding residents involves sitting at eye level to ensure clear communication and comfort for the resident. The Chief Clinical Officer also noted that feeding residents at eye level could prevent aspiration by allowing the CNA to visually monitor the resident's mouth. The facility's policy on dignity, revised in October 2024, was not adhered to in this instance, as the CNA's actions did not align with the established guidelines for maintaining resident dignity during meals.
Failure to Reassess PASARR for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to reassess the Preadmission Screening and Resident Review (PASARR) for a resident diagnosed with mental illness and placed on antipsychotic medication. The resident, who was admitted with diagnoses including unspecified psychosis, end-stage renal disease, anxiety disorder, and unspecified dementia, was not reassessed for PASARR Level 1 after being placed on antipsychotic medication. This oversight was identified during a review of the resident's records, which showed that the initial PASARR Level 1 Screening did not indicate a serious diagnosed mental disorder, and therefore, a Level 2 Screening was not conducted. The Director of Medical Records acknowledged missing the resident's status change and the need for a new PASARR Level 1 Screening. The Minimum Data Set Coordinator also confirmed that the facility missed the PASARR Screening, which should have been updated once the resident was placed on antipsychotic medication. The facility's policy requires a new Level 1 screening if there is a significant change in the resident's condition, but this was not done, potentially delaying necessary care and services for the resident.
Deficiencies in Medication Administration for Two Residents
Penalty
Summary
The facility failed to ensure the safe administration of blood pressure medications for two residents, leading to deficiencies in care. For Resident 129, the Licensed Vocational Nurse (LVN) did not mix the crushed Amlodipine medication with water before administering it via the gastrostomy tube (GT), resulting in medication residue remaining in the cup. This practice risked the resident not receiving the full dose of the medication, which is crucial for managing hypertension. The facility's policy required that medications be mixed with water and the cup rinsed to ensure the full dose is administered, but this was not followed. For Resident 80, the facility failed to reassess abnormal blood pressure values before administering medications with specific parameters. The LVN relied on blood pressure readings taken by a Certified Nurse Assistant (CNA) earlier in the morning, which were not verified before medication administration. The LVN initially decided to hold certain medications based on these unverified readings but later administered Metoprolol after rechecking the blood pressure. The facility's policy required that vital signs be checked before administering medications, especially those with parameters, but this was not adhered to. The deficiencies in medication administration for both residents highlight a lack of adherence to established protocols and procedures. Resident 129's cognitive impairment and dependence on staff for all activities of daily living further emphasize the need for careful medication management. Similarly, Resident 80's complex medical conditions, including hypotension and atrial fibrillation, necessitate precise monitoring and administration of medications. The failure to follow proper procedures placed both residents at risk of not receiving appropriate care.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medication carts were properly secured, leading to potential unauthorized access to medications. During a medication pass observation, a Licensed Vocational Nurse (LVN) left a medication cart unlocked and unattended in the hallway while attending to a resident. This oversight was noticed by a Registered Nurse (RN), who subsequently locked the cart. The facility's policy requires medication carts to be locked or attended by authorized personnel, highlighting a lapse in adherence to this policy. In another instance, a medication cart contained home medications for a resident, including a controlled substance, without a physician's order. The medications were brought from the resident's home and were not intended for use by the facility. The LVN responsible for the cart was unaware of the presence of a controlled medication, Lorazepam, among the home medications. The facility's policy dictates that unauthorized medications should not be accepted and should be returned to the family or disposed of if unclaimed. Additionally, the facility failed to properly label an opened medication for a resident, which could lead to the use of expired medication. An LVN found an opened foil pack of Ipratropium-Albuterol Inhalation Solution without an open date, contrary to manufacturer guidelines that require the medication to be used within two weeks of opening. This oversight could compromise the medication's potency, potentially affecting the resident's treatment for breathing issues.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food requests and preferences of a resident, identified as Resident 76, which had the potential to impact her nutritional needs. Resident 76, who has diabetes mellitus and pulmonary hypertension, was on a controlled carbohydrate diet and had specific food preferences documented, such as brown rice and wheat bread. Despite these documented preferences, the resident reported that the kitchen frequently ran out of requested items like gravy, chicken noodle soup, bacon, and cream of wheat, leading to her receiving alternative foods that did not align with her preferences. This issue was corroborated by interviews with staff, including a Certified Nursing Assistant and a Dietary Aide, who confirmed that popular food items often ran out, affecting residents' satisfaction and potentially their appetite. The Dietary Supervisor admitted to not regularly checking in with residents unless there was a complaint, indicating a lack of proactive engagement with residents' dietary needs. The facility's policy on food preferences, which requires staff to assess and document individual preferences, was not effectively implemented, as evidenced by the miscommunication between nursing and kitchen staff. The Assistant Cook acknowledged that additional food could be prepared to meet residents' requests, but this was not consistently done, leading to dissatisfaction among residents like Resident 76, who expressed a preference for specific items such as raisin toast and bacon.
Deficiency in QAPI Committee's System for Resident Safety
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to establish a system for medication management and safety, falls and fall-related injuries, and pressure ulcers monitoring. This deficiency resulted in residents not receiving necessary care, leading to medication errors, injuries related to falls, and inadequate monitoring and documentation of pressure injuries. During an interview, the Administrator acknowledged the ongoing work but could not provide evidence of measures to prevent medication errors, falls, and pressure injuries. The facility's policy and procedure, revised in January 2025, indicated a need for a systematic and proactive process to improve resident care, outcomes, and safety, which was not effectively implemented.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program policy when administering antibiotics to a resident without meeting the established criteria for appropriate use. Specifically, Resident 98 was prescribed Ampicillin Sodium Injection Solution for a urinary tract infection, despite not meeting Loeb's or McGeer's criteria for antibiotic use. This oversight was identified during a review of the resident's records, which showed no documentation indicating that the physician was notified about the lack of criteria fulfillment. Resident 98, who was admitted with conditions including hemiplegia, hemiparesis, and neuromuscular dysfunction of the bladder, was receiving antibiotics without proper justification. The Director of Quality Assurance confirmed that the resident's symptoms did not meet the necessary criteria and acknowledged the absence of physician notification. The Chief Clinical Officer also noted the potential negative outcomes of administering antibiotics without meeting the criteria, such as the risk of multidrug-resistant organisms.
Failure to Offer and Document Influenza Vaccination
Penalty
Summary
The facility failed to offer, educate, and track influenza vaccinations for residents as per its policy, specifically for one of the five sampled residents. Resident 218, who was admitted with a diagnosis of hemiplegia and hemiparesis following a cerebrovascular infarction, was found to have moderately impaired cognition and was dependent on assistance for hygiene, bathing, and dressing. Despite being eligible for the 2024-2025 influenza vaccine, there was no documentation indicating that the vaccine was offered, education was provided, or that the resident declined the vaccine. During interviews, the Director of Quality Assurance confirmed the lack of documentation and emphasized the importance of offering vaccinations to prevent the spread of infection. The Chief Clinical Officer also highlighted the significance of offering the influenza vaccine to protect residents and prevent potential outbreaks. The facility's policy, revised in October 2019, mandates offering the vaccine to all eligible residents and employees, providing education on its benefits and side effects, and documenting the vaccination or refusal in the medical record. However, these procedures were not followed for Resident 218, leading to the deficiency.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer, educate, and document coronavirus vaccinations for two residents, which was not in compliance with the facility's policy. Resident 218, who was admitted with hemiplegia and hemiparesis following a cerebrovascular infarction, had moderately impaired cognition and was dependent on assistance for hygiene, bathing, and dressing. Despite being eligible for the 2024-2025 coronavirus vaccine, there was no documentation indicating that the vaccine was offered, education was provided, or that the resident declined the vaccine. Similarly, Resident 121, who was admitted with chronic respiratory failure and dependence on a respirator, had severely impaired cognition and was also dependent on assistance for hygiene, bathing, and dressing. The facility's records did not show that the 2024-2025 coronavirus vaccine was offered, education was provided, or that the resident declined the vaccine. The Director of Quality Assurance confirmed the lack of documentation and emphasized the importance of offering vaccinations to prevent the spread of infection. The facility's policy required that all residents be offered vaccines unless medically contraindicated, and that education and any refusals be documented in the resident's medical record.
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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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