Tarzana Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tarzana, California.
- Location
- 5650 Reseda Blvd, Tarzana, California 91356
- CMS Provider Number
- 056124
- Inspections on file
- 100
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Tarzana Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with muscle weakness, diverticulitis with perforation and abscess, and moderately impaired cognition, who required varying levels of assistance with ADLs, was observed in bed with the call light not within reach, hanging behind the headboard. During a subsequent observation and interview, an LVN confirmed the call light was out of reach and repositioned it next to the resident’s hand, stating call lights should always be next to residents and that CNAs are responsible for ensuring accessibility. The DON later affirmed that call lights must be clipped by the bed and within reach so residents can call for assistance, and facility policy requires staff to ensure the call system is accessible to residents while in bed.
A resident admitted with CHF and moderate cognitive impairment did not receive a baseline care plan within 48 hours of admission to address CHF-related needs. The MDS nurse, responsible for initiating diagnosis-related care plans, confirmed that no CHF-specific baseline care plan existed, even though the resident required assistance with multiple ADLs. The DON acknowledged that baseline care plans are important on admission, and facility policy requires timely development of a baseline care plan including goals, physician and dietary orders, and interventions based on admission information, but these requirements were not followed for this resident’s CHF diagnosis.
A resident with metabolic encephalopathy, impaired gait, and lack of coordination, whose care plan required a mechanical lift with two staff for transfers, was observed on a shower chair with a lift sling attached while only one CNA operated the mechanical lift controls, briefly raising and lowering the resident. The CNA reported she attempted to adjust the tall resident’s position to prevent the resident’s head from touching the lift bar and did so without waiting for a second staff member, despite knowing the resident was a two-person assist. The DON confirmed that mechanical lift transfers are to be performed with two staff, consistent with facility policy on accidents and supervision.
A resident with diastolic CHF and HTN had physician orders for furosemide and losartan that included hold parameters for systolic blood pressure (SBP) less than 110 mmHg and, for losartan, heart rate less than 60 bpm. Review of the MAR and interview with the MDS nurse showed that licensed nurses administered both medications on two occasions when the resident’s SBP was below the ordered threshold. The MDS nurse confirmed the medications should have been held according to the orders, and the facility’s medication administration policy required obtaining vital signs and holding medications when they fell outside prescribed parameters.
A resident with intact cognition and multiple conditions, including CHF, HTN, and type 2 DM, repeatedly refused ordered potassium chloride and metoprolol succinate over multiple consecutive days, as documented on the MAR. An LVN acknowledged the resident’s repeated refusals and stated that facility practice is to notify the physician after three or more refusals, but also acknowledged not documenting any physician notification. The DON confirmed the pattern of refusals and the expectation that the physician be notified after three consecutive refusals, while facility policy required reporting and documenting medication refusals, yet there was no documentation that the physician had been informed.
A resident with intact cognition and multiple comorbidities, including chronic respiratory failure, pneumonia, dysphagia, DM2, CHF, and HTN, required assistance with ADLs such as toileting hygiene and showering. Review of the medical record by the MRD showed that full body skin assessments were documented only a few times during the stay, rather than on a weekly basis. The facility’s Skin Assessment P&P required a head-to-toe skin assessment by an RN or LPN on admission/readmission and weekly thereafter, as well as after changes in condition or new pressure injuries. The DON acknowledged that licensed nurses should have completed weekly skin assessments for this resident, but the record lacked documentation of consistent weekly assessments as required.
A resident with dementia, hearing loss, and impaired vision had care plans requiring use of eyeglasses and hearing aids when out of bed, with staff responsible for ensuring these devices were worn and functioning. During observation, the resident was seen in a wheelchair in the lobby without eyeglasses or hearing aids. The ADON and an LVN both acknowledged the resident should have been wearing these devices, and the LVN reported the hearing aids were not charged and thus unavailable, despite the documented plan of care and facility policies requiring assistance with hearing aids and implementation of comprehensive care plans.
A resident with severely impaired cognition, dependence in ADLs, and a left humerus fracture did not receive a recliner wheelchair that had been recommended by PT due to poor sitting balance and a non–weight-bearing upper extremity. The DORS did not order the recliner wheelchair because she believed it was not covered under Medicare Part A, despite facility policy and Medicare guidance indicating DME is covered under the SNF PPS. The DON later confirmed that the failure to order the recliner wheelchair and communicate with nursing caused a delay in treatment with potential for functional decline and decreased mobility.
A resident with a history of PTSD and major depressive disorder did not have a comprehensive care plan addressing PTSD, despite staff awareness and documented trauma history. The care plan lacked specific interventions for PTSD, contrary to facility policy requiring person-centered plans for all identified needs.
A resident with a history of PTSD and major depressive disorder did not receive appropriate behavioral health services beyond psychiatric visits, despite staff awareness and documentation of her condition. Facility staff confirmed that no additional interventions or assessments were implemented to address her PTSD, contrary to facility policy requiring person-centered behavioral health care.
A resident who lacked capacity to make decisions due to medical conditions had their admission packet e-signed by themselves instead of their designated representative. Facility staff and policy confirmed that the representative should have signed, but this did not occur, resulting in the resident not being properly represented in healthcare decisions.
During a COVID-19 outbreak, staff failed to follow infection control protocols, including improper mask use by two staff members, lack of hand hygiene by a therapist and a housekeeper after resident care and trash handling, and unsafe transport of trash bags in contact with clothing. These actions did not align with facility policy and CDC guidelines for infection prevention.
A resident did not receive the medically-related social services needed to achieve the highest possible quality of life, resulting in unmet social and psychosocial needs.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with severe cognitive impairment and multiple health conditions experienced a delay in laboratory testing after developing diarrhea. The initial stool specimen was not picked up by the lab, causing a delay in obtaining and processing a second sample. This resulted in a delayed diagnosis of C. diff and a subsequent delay in starting antibiotic treatment, contrary to facility policy requiring timely lab services.
A resident did not receive a comprehensive explanation or proper informed consent for a psychotropic medication, as the consent form lacked the physician's signature and dose frequency. Additionally, two residents were not informed of the names and indications of several medications before administration by an LPN, contrary to facility policy. These actions prevented residents from being fully informed and involved in their care.
A resident with limited mobility and a history of fractures did not receive active range of motion (AROM) exercises to both arms as recommended by occupational therapy. The care plan and restorative nursing aide documentation only included AAROM to the legs, and staff interviews confirmed that the AROM task for the arms was not entered into the electronic system. This omission resulted in the resident not receiving the prescribed interventions to maintain upper extremity range of motion.
Surveyors found multiple deficiencies, including a shower room with standing water and a leaking shower head that were not reported or repaired, incomplete and inaccurate fall risk assessments after resident falls, and failure to implement care plan interventions such as keeping beds in low positions and providing padded siderails for seizure precautions. These lapses involved residents with cognitive impairment, seizure disorders, and fall risks, and staff acknowledged the importance of these interventions and assessments.
Multiple residents did not receive prescribed medications as ordered due to lapses in pharmacy delivery, failure to reorder in advance, and staff not following physician parameters for administration. This included missed doses of antidepressants, migraine medication, vitamin D supplements, and improper administration of blood pressure and bowel management medications, with staff and leadership confirming these errors.
Two residents experienced medication errors when one did not receive a prescribed vitamin D supplement due to unavailability, and another received a calcium with vitamin D supplement outside the scheduled time window. These incidents resulted in a medication error rate above 5%, as facility staff did not follow established medication administration protocols.
An LVN prepared six medications for a resident and left them unattended on top of a medication cart while entering the resident's room to take vital signs. The medications remained unsupervised and accessible until the LVN returned to administer them in two trips. Both the LVN and DON acknowledged that this action failed to meet the facility's policy for safe and secure medication storage, which requires medications to be attended or locked at all times.
The facility did not consistently follow infection control protocols, including failing to use enhanced barrier precautions for a resident with a gastrostomy tube, not labeling or timely replacing oxygen tubing for two residents, and not labeling a urinal with a resident identifier. These actions were not in accordance with facility policy and staff expectations, as confirmed by interviews and record reviews.
Two residents experienced lapses in dignity and privacy when one resident's urinary catheter bag was left uncovered, and another resident was not afforded privacy during bathing as staff repeatedly entered the shower room without knocking. These actions were inconsistent with facility policies requiring the use of privacy bags for catheter drainage and staff to knock before entering rooms occupied by residents.
A resident with severe cognitive impairment and a history of falls was found with their call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible. This was confirmed by a CNA and acknowledged by the DON.
A resident with bilateral lower extremity amputations showed significant improvement in performing sit-to-stand transfers with prosthetic legs, but this change was not documented or reported to the physician as required. As a result, the resident did not receive further PT services to support increased independence with mobility.
A resident with a history of left femur fracture and ongoing mobility issues was not accurately assessed for range of motion (ROM) limitations in three consecutive MDS assessments. Despite therapy evaluations, care plans, and staff observations confirming a left leg ROM impairment and the need for assistance, the MDS documentation repeatedly indicated no ROM limitations. This resulted in inaccurate information being reported in the federal database.
The facility did not develop care plans for two residents: one requiring continuous oxygen therapy for respiratory failure and another receiving regular hydromorphone for chronic pain. In both cases, staff confirmed that care plans addressing these specific needs were missing, despite facility policy requiring comprehensive, measurable care plans for all identified resident needs.
The facility did not timely update care plans for two residents: one with epilepsy did not have a care plan intervention for padded side rails added after a physician's order, and another with an indwelling catheter did not have their care plan reviewed or revised for over six months. Staff confirmed that care plans are required to be reviewed quarterly and after changes in condition, but these requirements were not met, resulting in deficiencies in individualized care.
A resident with recent knee surgery and mobility limitations was unable to participate in transfers or therapy for 12 days due to the facility's failure to provide a properly fitting knee immobilizer. Therapy and nursing documentation showed the resident remained bedbound, and interviews confirmed the resident experienced sadness and depression as a result. The delay in obtaining the necessary device led to a preventable decline in the resident's ability to perform activities of daily living (ADLs) and maintain mobility.
A resident requiring partial to moderate assistance with ADLs, including bathing, was not consistently offered or provided showers or bed baths according to facility policy. Staff failed to document whether bathing was offered, received, or refused on multiple days, and did not ask the resident for her bathing preference, resulting in inadequate personal hygiene care.
A resident with a history of diabetes, a foot ulcer, and prior DVT did not receive ordered vascular studies or a follow-up with a vascular surgeon after a staff transition led to a lapse in care coordination, despite these needs being documented in the care plan and medical record.
A resident with a stage 4 pressure ulcer and severe cognitive impairment was found with a low air loss (LAL) mattress set incorrectly at 225 lbs instead of the required 87 lbs, as indicated on the mattress. This error was confirmed by an LVN and occurred despite physician orders and care plans specifying the need for proper mattress settings to manage the resident's wound. The facility's policy and the manufacturer's guide both emphasized the importance of correct support surface settings for pressure injury prevention and care.
Two residents with indwelling catheters did not receive proper care: one did not receive catheter care or monitoring after hospital readmission due to missing physician orders, and another had a catheter collection bag positioned at bladder level instead of below, contrary to policy and care plan requirements.
A resident with a rib fracture and severe pain received PRN hydromorphone on several occasions without documentation that nonpharmacological pain interventions were attempted first, as required by physician orders and facility policy. Staff interviews confirmed the lack of documentation and awareness of the policy requirements.
A resident with multiple chronic conditions and impaired cognition had several PRN medications ordered for constipation. The Consultant Pharmacist recommended reviewing all PRN constipation medications and specifying the sequence for administration, but facility staff did not act on this recommendation or update the physician's orders as required by policy.
A resident with depression and a history of stroke did not receive prescribed doses of Paxil for several days due to a lapse in medication delivery and failure to reorder in a timely manner. Pharmacy records and staff interviews confirmed the medication was unavailable and not administered as scheduled, contrary to facility policy.
A resident with bilateral leg amputations and new prosthetic legs was discharged from PT after only six sessions, despite documented improvement and continued need for therapy. The resident, who was motivated to walk and had made progress in transfers and ambulation, was transitioned to RNA services limited to sit-to-stand training. The therapy team did not document communication with the physician to seek an extension of PT services, and the facility's actions did not align with its policy to restore residents to their highest level of function.
Two residents experienced deficiencies in medical record documentation: one had wound care treatment documented before it was actually provided, and another had an incomplete Change in Condition evaluation after a fall. These actions were not consistent with professional standards or facility policy, resulting in inaccurate and incomplete records.
Two residents were subjected to verbal abuse, one by a CNA who responded to a resident's remarks with profanities after removing a dinner tray without consent, and another by a roommate who repeatedly used offensive and discriminatory language. Staff and administration confirmed these actions met the facility's definition of verbal abuse, and multiple staff witnessed or were aware of the incidents.
A resident with cognitive impairment and total dependence on staff reported repeated verbal abuse, including discriminatory remarks, from a roommate. Multiple CNAs witnessed the incidents but did not report them, assuming others were aware. Facility leadership was unaware of the abuse, and required notifications to authorities were not made within the mandated timeframe, resulting in unaddressed abuse and lack of protection for the resident.
A resident with end stage renal disease and cognitive impairment did not have a physician's order documented to discontinue hemodialysis or to arrange for permcath removal, despite a directive from the dialysis center. The responsible RN failed to document the necessary communication and obtain the required order, resulting in a delay in permcath removal and potential risk for infection.
The facility did not complete trauma assessments for three residents with complex medical and psychosocial needs, despite evidence of cognitive impairment, fluctuating decision-making capacity, and incidents that could trigger trauma responses. Staff interviews revealed confusion over responsibility for trauma assessments, and record reviews confirmed the absence of required documentation, contrary to facility policy on trauma-informed care.
A resident with multiple complex medical conditions, including a pressure ulcer and gastrostomy tube, received wound care as ordered by the physician, but the LPNs responsible did not document the completion of these treatments in the TAR. The DON confirmed that documentation should have been completed per facility policy.
A resident with legal blindness and high fall risk was found in bed with the bed in a high position and a required side rail down, contrary to the care plan and physician order. Staff confirmed the side rail should have been up for mobility and fall prevention, and facility policy required adherence to individualized care plans.
A resident with diabetes was given insulin lispro significantly earlier than prescribed, with the injection occurring well before the dinner meal was served. The nurse administered the insulin ahead of schedule and did not provide a snack to the resident, contrary to physician orders and facility policy requiring medications to be given as directed.
A nurse administered a resident's scheduled morning medications, including Keppra for seizures, more than one hour after the prescribed time. Facility policy and the DON confirmed that medications should be given within one hour of the scheduled time, but this standard was not met during the observed medication pass.
Two patients did not have their call lights accessible or answered promptly. One patient with severe cognitive impairment and mobility issues had a call light out of reach on the floor, while another patient at high risk for falls had an activated call light ignored by a CNA who was not assigned to her. Facility policy requires all staff to ensure call lights are within reach and to respond to any activated call light.
A CNA failed to wear gloves and a gown when delivering and retrieving a lunch tray for a resident on contact isolation for an infectious disease, despite facility policy and signage requiring full PPE. The DON confirmed that staff must use complete protective equipment in such situations to prevent infection spread.
A resident with epilepsy did not receive prescribed doses of Lacosamide (Vimpat) and Clobazam on multiple occasions due to the medications not being available in the facility. Documentation in the MAR and nursing progress notes confirmed the unavailability, and interviews with the resident and nursing staff further substantiated the missed doses. Facility policy required timely medication acquisition and administration, but this was not followed, resulting in the deficiency.
Licensed nurses failed to document the administration of Norco for a resident with chronic pain syndrome on the Medication Administration Record (MAR) after signing the Controlled Drug Record (CDR), resulting in incomplete health records and lack of pain assessment documentation, as confirmed by both the nurse and DON.
Failure to Keep Call Light Within Reach of Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach while the resident was in bed. The resident had been originally admitted in late January and re-admitted in late April with diagnoses including muscle weakness and diverticulitis of the large intestine with perforation and abscess with bleeding. An MDS assessment indicated the resident had moderately impaired cognitive skills for daily decision-making, required setup or clean-up assistance with eating, supervision with oral hygiene, partial/moderate assistance with toileting hygiene, and substantial/maximal assistance with showering or bathing. During an observation in the resident’s room, the resident was seen in bed with the call light not within reach, hanging on the wall behind the headboard. In a concurrent observation and interview with an LVN in the same room, the resident remained in bed with the call light still not within reach, again observed hanging behind the headboard. The LVN then reached over the headboard, clipped the call light, and placed it next to the resident’s right hand, stating that the call light should always be next to the resident for safety and that CNAs are responsible for ensuring call lights are within residents’ reach because they are always checking on residents. In a separate interview, the DON stated that call lights should always be within residents’ reach, clipped by the bed, so residents can easily call staff when they need help or assistance, and that if call lights are not within reach, residents may not be able to call for assistance when needed. Review of the facility’s policy on call lights indicated staff will be educated on proper use of the call light system and must ensure the call light is within reach of the resident and accessible while the resident is in bed or other sleeping accommodations.
Failure to Develop Baseline Care Plan for CHF on Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission to address a resident’s primary admitting diagnosis of congestive heart failure (CHF). The resident was admitted with CHF and had an MDS assessment showing moderately impaired cognitive skills for daily decision-making and functional needs including assistance with oral hygiene, eating, personal hygiene, and dependence for toileting hygiene and bathing. Review of the admission record and baseline care plans showed no documented baseline care plan specific to CHF, despite CHF being the primary admitting diagnosis. The MDS nurse, who stated that diagnosis-related care plans are initiated by the MDS department, confirmed that there was no baseline care plan for CHF and acknowledged that one should have been in place. The DON stated that baseline care plans are important to be initiated on admission to ensure nursing staff provide appropriate care based on admitting diagnoses and to allow staff to evaluate and revise interventions as needed. The facility’s own policy titled “Baseline Care Plan,” last reviewed on 4/24/2025, requires that a baseline care plan be developed within 48 hours of admission and include minimum healthcare information such as initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. The policy also specifies that the admitting or supervising nurse must gather information from the admission assessment, hospital transfer information, physician orders, and discussions with the resident or representative to establish initial goals and interventions addressing current needs and health and safety concerns. Despite these requirements, no baseline care plan addressing the resident’s CHF was developed within the required timeframe.
Single-Staff Use of Mechanical Lift Contrary to Two-Person Transfer Requirement
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who required a mechanical lift with two-person assistance for transfers received that level of assistance. The resident had diagnoses including metabolic encephalopathy, abnormalities of gait and mobility, and lack of coordination, and an H&P documented that the resident did not have the capacity to understand or make decisions. The resident’s MDS showed a need for assistance with several ADLs, and the care plan for ADL self-care performance specified that transfers required a mechanical lift with two staff assisting. During observation, the resident was seated on a shower chair with a mechanical lift sling in place and the sling straps attached to the lift hooks when a single CNA operated the mechanical lift controls, briefly elevating the resident from the shower chair and then lowering the resident back down. In an interview, the CNA stated she was assigned to the resident on the day of the incident and that it was the resident’s shower day. She reported she was setting up the resident on the mechanical lift and waiting for another CNA to assist with transferring the resident back to bed when she noticed the resident’s forehead touching the metal bar of the lift. Because the resident was tall, she decided to elevate the resident from the shower chair and adjust the resident and the lift so the resident’s head would not contact the bar, doing so without a second staff member present. The CNA acknowledged she knew the resident was a two-person assist and that she made a mistake by elevating and moving the lift alone. The DON confirmed that facility practice and expectations are that two staff members are present when using a mechanical lift for transfers to ensure resident safety, and the facility’s Accidents and Supervision policy stated that residents will receive adequate supervision and assistive devices to prevent accidents.
Failure to Hold Antihypertensive Medications Outside Ordered BP Parameters
Penalty
Summary
The facility failed to ensure that licensed nurses held a resident’s antihypertensive medications when the resident’s blood pressure was outside the physician’s ordered parameters. Resident 1 was admitted with diagnoses including diastolic congestive heart failure and essential hypertension, and had moderately impaired cognitive skills for daily decision making, requiring varying levels of staff assistance with activities of daily living. Physician orders for this resident included furosemide 40 mg by mouth once daily for diastolic heart failure, to be held for systolic blood pressure (SBP) less than 110 mmHg, and losartan 12.5 mg by mouth once daily for hypertension, to be held for SBP less than 110 mmHg or heart rate less than 60 beats per minute. Review of the Medication Administration Record for the month showed that licensed nurses administered both furosemide and losartan to the resident on two occasions when the SBP was below the ordered hold parameter: once with an SBP of 107 mmHg and once with an SBP of 98 mmHg. During interview, the MDS nurse confirmed that the medications should not have been administered on those dates based on the physician’s parameters and acknowledged that nurses are expected to obtain vital signs prior to giving blood pressure medications and to hold medications when vital signs fall outside the prescribed limits. The facility’s medication administration policy stated that medications are to be administered as ordered by the physician, including obtaining and recording vital signs when applicable and holding medications when vital signs are outside the physician’s prescribed parameters, which was not followed in this case.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician after multiple refusals of prescribed medications. The resident was admitted with chronic respiratory failure, pneumonia, dysphagia, type 2 DM, CHF, and HTN, and had documented capacity and intact cognition. Physician orders included daily potassium chloride 20 mEq as a supplement related to Lasix use and metoprolol succinate 50 mg daily for HTN. Review of the MAR for February showed the resident refused potassium chloride on multiple consecutive days (2/17–2/19 and 2/23–2/28) and refused metoprolol succinate on multiple series of consecutive days (2/3–2/6, 2/9–2/12, 2/16–2/18, and 2/20–2/22). The March MAR showed continued refusals of potassium chloride on multiple consecutive days (3/4–3/9 and 3/11–3/14). During interview, an LVN who administered medications to the resident acknowledged that the resident sometimes refused ordered medications and stated that when a resident refuses medication three or more times, the physician should be notified. The LVN further stated that they did not document that the physician was notified of the resident’s medication refusals. In a concurrent interview and record review, the DON confirmed that the MARs showed multiple refusals of potassium chloride and metoprolol succinate and stated that nursing staff should notify the prescribing physician when a resident refuses medications three consecutive times. The facility’s Medication Administration policy indicated that medications are to be administered as ordered by the physician and that staff must report and document any refusals, but there was no documentation that the physician was notified of these repeated refusals.
Failure to Complete Weekly Skin Assessments per Facility Policy
Penalty
Summary
The facility failed to complete weekly skin assessments for one resident in accordance with its Skin Assessment policy and procedure. The resident was admitted on 1/19/2026 with multiple diagnoses, including chronic respiratory failure, pneumonia, dysphagia, type 2 diabetes, congestive heart failure, and hypertension. A History and Physical dated 1/20/2026 documented that the resident had the capacity to understand and make decisions, and a Minimum Data Set dated 1/26/2026 indicated intact cognition. The MDS further showed the resident required set-up assistance with eating, supervision with oral hygiene, upper body dressing, and personal hygiene, and was dependent on staff for toileting hygiene and showering. During interview and record review, the Medical Records Director stated that the resident’s skin assessments were documented only on 1/19/2026, 1/20/2026, 2/2/2026, and 3/1/2026, and confirmed there were no other documented skin assessments in the medical record. The facility’s Skin Assessment policy, last reviewed on 4/24/2025, required a full body, head-to-toe skin assessment by a licensed or registered nurse upon admission or readmission and weekly thereafter, and additionally after a change of condition or any newly identified pressure injury. The Director of Nursing stated that licensed nurses should have conducted the resident’s weekly skin assessments during the admission, but the documentation showed that weekly assessments were not consistently completed as required by the policy.
Failure to Implement Care Plan for Vision and Hearing Devices
Penalty
Summary
Surveyors identified a deficiency in the implementation of a resident’s comprehensive care plan related to vision and hearing needs. The resident was admitted with diagnoses including metabolic encephalopathy, UTI, hearing loss, and dementia, with assessments showing severely impaired cognition and dependence on staff for most ADLs. The resident’s care plan for impaired visual function, revised 1/6/2026, directed staff to remind the resident to wear glasses when up and to ensure the glasses were worn, clean, free from scratches, and in good repair. A separate care plan for communication problems related to bilateral hearing loss, revised 1/7/2026, indicated the resident required hearing aids to communicate and that staff were to ensure the availability and functioning of adaptive communication equipment. On observation on 2/26/2026 at 1:45 p.m., the resident was seen sitting in a wheelchair in the lobby without eyeglasses or hearing aids in place. During a concurrent observation and interview at 1:50 p.m., the ADON confirmed that the resident should be wearing eyeglasses and hearing aids when out of bed. In a later interview at 2:45 p.m., an LVN stated the resident should be wearing hearing aids and eyeglasses when out of bed, but reported the hearing aids were not currently charged and therefore not available for the resident to wear, despite the plan of care requiring their use. The Administrator also confirmed that the resident should be wearing hearing aids and eyeglasses when out of bed as indicated in the care plans. Facility policies on care and use of hearing aids and on comprehensive care plans required assistance with hearing aids and implementation of person-centered care plans with measurable objectives and timeframes to meet identified needs.
Failure to Provide Recommended Recliner Wheelchair DME
Penalty
Summary
The facility failed to provide a recliner wheelchair, a recommended piece of DME, to a resident following a physical therapist’s assessment and order. The resident had been readmitted with diagnoses including an unspecified displaced fracture of the neck of the left humerus, UTI, and metabolic encephalopathy, and had a Minimum Data Set indicating severely impaired cognition and dependence on staff for toileting hygiene, bathing, dressing, personal hygiene, and mobility. On 12/26/2025, Physical Therapist 1 documented that the resident was compliant with skilled interventions, required extra time to process new information, and recommended a recliner wheelchair due to poor sitting balance and a non–weight-bearing left upper extremity. Despite this recommendation, the resident did not receive a recliner wheelchair and was later observed awake and lying in bed. The Director of Rehabilitation Services stated that the resident did not have a recliner wheelchair and explained that she initially believed the recliner wheelchair would not be covered under Medicare Part A, so she did not order it. After reviewing the Medicare Benefit Policy Manual, she acknowledged that the recliner wheelchair should have been ordered at the time of the therapist’s recommendation and that it was important to follow the recommendation to prevent the resident from sliding or falling forward from the wheelchair. The DON confirmed that the recliner wheelchair should have been ordered following the therapist’s assessment and that the failure of the Director of Rehabilitation Services to order the equipment and communicate with nursing resulted in a delay in treatment, with the potential to cause functional decline and decreased mobility. The facility’s policy, based on the Medicare Benefit Policy Manual Chapter 8, indicated that DME for Part A inpatients is covered as part of the SNF prospective payment system and is not separately payable.
Failure to Develop PTSD-Specific Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed a resident's history of post-traumatic stress disorder (PTSD). The resident was admitted with diagnoses including major depressive disorder and had a positive trauma screen, with documentation indicating a history of trauma related to an attempted assault in her 20s. The resident's Minimum Data Set showed intact cognitive skills and a need for assistance with daily activities. Despite these findings and a psychiatric note confirming ongoing PTSD-related anxiety, the care plan did not specifically address PTSD. During interviews and record reviews, it was confirmed that staff were aware of the resident's PTSD, but no care plan interventions specific to PTSD were in place. The Assistant Director of Nursing acknowledged that a care plan for PTSD should have been developed, including interventions such as referral to a female psychologist. The facility's policy requires comprehensive care plans with measurable objectives and timeframes for all identified needs, but this was not followed for the resident's PTSD.
Failure to Provide Resident-Centered Behavioral Health Services for PTSD
Penalty
Summary
The facility failed to provide resident-centered behavioral health services to a resident with a documented history of post-traumatic stress disorder (PTSD) and major depressive disorder. The resident was admitted with these diagnoses, and assessments, including the Trauma Informed Care Screener and the Minimum Data Set, confirmed both the presence of trauma and intact cognitive skills. Despite the resident's disclosure of PTSD to staff and documentation in the care plan and psychiatric notes indicating ongoing PTSD-related anxiety, the facility did not implement specific behavioral health interventions beyond psychiatric visits. Interviews with facility staff, including the LVN, DON, and ADON, revealed that no additional behavioral health services or interventions were provided to address the resident's PTSD. Staff acknowledged awareness of the resident's condition but confirmed that no assessments or services were in place to identify triggers or prevent behavioral responses related to PTSD. The facility's own policy required person-centered behavioral health care, but this was not followed for the resident in question.
Failure to Obtain Representative Signature for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure that a resident who lacked decision-making capacity had their admission packet e-signed by their designated representative. Instead, the admission assistant obtained an electronic signature from the resident, despite documentation in the resident's History and Physical (H&P) examinations indicating the resident did not have the capacity to understand or make decisions due to conditions such as metabolic encephalopathy, urinary tract infection, immunodeficiency, and dementia. The admission occurred after the resident was diagnosed with these conditions, and both the H&P dated shortly after admission and a subsequent H&P confirmed the resident's incapacity. During interviews and record reviews, both the admission assistant and the admission director acknowledged that the resident's representative should have been the one to e-sign the admission packet, as per the facility's policy and the resident's documented incapacity. The facility's policy states that a resident's representative has the right to exercise the resident's rights to the extent those rights are delegated. The failure to have the representative sign the admission documents resulted in the resident not being rightfully represented in important healthcare decisions.
Failure to Implement Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection control practices during an ongoing COVID-19 outbreak, as evidenced by multiple staff not adhering to mask-wearing protocols and hand hygiene requirements. Specifically, two staff members, an Activity Assistant and a Certified Occupational Therapy Assistant, were observed wearing surgical masks below their noses, only covering their mouths, while in resident care areas. Both staff acknowledged awareness of the ongoing outbreak and their training on proper mask use, but did not maintain correct mask positioning during their duties. Additionally, hand hygiene lapses were observed among staff. A Physical Therapist did not perform hand hygiene after removing gloves and before touching a resident and their wheelchair following a therapy session. The therapist admitted that hand hygiene should have been performed to prevent the spread of germs. Similarly, a Housekeeping staff member failed to perform hand hygiene after handling trash in a restroom and before touching the janitor cart. The staff member acknowledged the lapse and the importance of hand hygiene in infection control. Further, the same Housekeeping staff member was observed transporting four trash bags with bare hands, allowing the bags to come into contact with her clothing. The staff member stated that the bags were heavy and difficult to keep away from her body. The Director of Nursing confirmed that a cart should have been used to prevent cross-contamination. Facility policies and CDC guidelines reviewed during the survey supported the need for proper mask use, hand hygiene, and safe trash handling to prevent the transmission of infectious diseases.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that indicated residents did not receive adequate social services support as required to address their individual needs and promote their well-being. The lack of appropriate social services limited residents' ability to attain or maintain their optimal physical, mental, and psychosocial functioning.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Delay in Laboratory Services Resulted in Delayed Diagnosis and Treatment
Penalty
Summary
The facility failed to provide timely laboratory services as ordered by a nurse practitioner for a resident with multiple medical conditions, including thyroid disorder, diabetes mellitus, and obesity. The resident, who was severely cognitively impaired and fully dependent on staff for care, experienced a change in condition marked by three episodes of foul-smelling diarrhea. The nurse practitioner ordered laboratory tests, an anti-diarrheal solution, and a registered dietician consult. A physician order was placed to collect a stool specimen, which was collected and stored in the refrigerator. However, the laboratory did not pick up the initial stool specimen, resulting in a delay in obtaining a second specimen. The second specimen was sent out two days later, and the positive result for C. difficile toxins was not received until several days after the initial collection. This delay in laboratory processing led to a delay in confirming the diagnosis and starting the necessary antibiotic treatment. Facility policy required timely provision of laboratory services, but this was not followed in this instance.
Failure to Obtain Informed Consent and Inform Residents of Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and able to participate in their care and treatment, specifically regarding medication administration and informed consent for psychotropic medications. For one resident with diagnoses including post-traumatic stress disorder and schizophrenia, the facility did not obtain a complete informed consent for the administration of Zyprexa, a psychotropic medication. The consent form lacked the physician's signature and did not specify the dose frequency. According to facility policy, the physician's signature is required to confirm that the risks and benefits of the medication were explained to the resident or their responsible party. The resident's records indicated that while the individual could make needs known, they could not make medical decisions, further emphasizing the importance of proper consent procedures. Additionally, during medication administration observations, a nurse failed to inform two residents of the names and indications of several medications prior to administration. The nurse admitted to not providing this information because the medication cups were not clearly labeled, which prevented the residents from being informed about their treatment and making choices such as refusing specific medications. The Director of Nursing confirmed that this omission was contrary to facility policy and restricted the residents' rights to be informed and involved in their care. The facility's own policies require that residents be informed in advance about the care and treatments they will receive, including the names and purposes of medications, and that informed consent be obtained for psychotropic medications. The failure to follow these procedures resulted in residents not being fully informed or able to participate in decisions regarding their care, as evidenced by the lack of proper consent documentation and the omission of medication information during administration.
Failure to Provide Recommended Active Range of Motion Exercises to Resident's Arms
Penalty
Summary
The facility failed to provide active range of motion (AROM) exercises to both arms for a resident with limited range of motion and mobility concerns, as recommended by occupational therapy (OT) upon discharge. The resident, who had a history of morbid obesity, healed traumatic fracture, and falls, was admitted with specific OT and physical therapy (PT) recommendations for restorative nursing aide (RNA) interventions. The OT discharge summary specifically recommended AROM to both arms, while the PT discharge summary recommended AROM to both legs. However, the resident's care plan and RNA documentation only included active assistive range of motion (AAROM) to both legs, with no mention or documentation of AROM to the arms. Multiple reviews of the resident's records, including the care plan, RNA documentation, and joint mobility assessments, confirmed that AROM to the arms was not provided or documented from January through June. Interviews with staff, including the RNA, interim director of rehabilitation, occupational therapist, and MDS coordinator, revealed that the OT's recommendations for AROM to both arms were not entered into the facility's electronic documentation system by the previous director of rehabilitation. As a result, the RNA program for the resident did not include the required AROM exercises for the arms, despite clear recommendations and supporting documentation from therapy staff. Observations further confirmed that the RNA only performed AAROM to the resident's legs and did not provide any ROM exercises to the arms. The facility's policy on prevention of decline in range of motion required interventions to maintain or improve ROM, but this was not followed in the resident's case. The failure to implement and document the recommended AROM exercises for both arms had the potential to result in a decline in the resident's upper extremity range of motion.
Failure to Prevent Accident Hazards and Implement Fall Risk Interventions
Penalty
Summary
A deficiency was identified when a shower room was found to have accident hazards, including a broken shower head leaking water onto the floor and a clogged drain resulting in approximately two inches of cloudy water accumulating in one of the showers. Maintenance staff confirmed that these issues had not been reported prior to the surveyor's observation, and acknowledged that such hazards could lead to slips and falls. Facility policy required prompt reporting and repair of non-functioning equipment to maintain a safe environment, but this was not followed in this instance. Another deficiency involved the failure to implement and accurately complete fall risk assessments for residents after falls. In one case, a resident with a history of falls and cognitive impairment experienced a fall, but the post-fall risk assessment was incomplete, omitting critical information such as recent fall history, gait and balance status, and predisposing diseases. In a separate case, a resident's post-fall risk assessment was inaccurately completed, with the nurse failing to document the correct number of falls in the past three months, resulting in a lower risk score than appropriate. Facility policy required thorough and accurate completion of fall risk assessments to guide interventions, but this was not adhered to. Additional deficiencies were observed in the implementation of care plan interventions. One resident, identified as being at risk for falls, was found in bed with the bed in a high position, contrary to the care plan directive to keep the bed in the lowest position. Staff confirmed the bed should have been kept low to prevent injury. Another resident with a seizure disorder and a care plan intervention for padded siderails was observed in bed without the required padding. Nursing staff acknowledged that the absence of padded siderails did not align with the care plan and could result in injury during a seizure. These findings demonstrate failures to follow individualized care plans and facility policies designed to prevent accidents and injuries.
Medication Availability and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the timely availability and administration of prescribed medications for multiple residents, resulting in missed doses and medication errors. One resident with depression and a history of stroke did not receive the antidepressant Paxil from 5/31/2025 to 6/04/2025 due to a lapse in pharmacy deliveries, as confirmed by pharmacy records and staff interviews. The same resident also experienced a gap in the availability of Sumatriptan, a medication for migraines, which was not available for several days and had to be supplied by a family member after insurance issues delayed pharmacy delivery. Staff and the DON acknowledged that the medications were not available as required, and the facility's own policies for medication reordering and handling unavailable medications were not followed. Another resident with chronic kidney disease and heart failure was prescribed Hydralazine for hypertension, with specific instructions to hold the medication if systolic blood pressure was below 120 mmHg. However, the MAR showed that Hydralazine was administered on multiple occasions when the resident's systolic blood pressure was below the prescribed threshold. The nurse involved confirmed that the medication should have been held according to the physician's order, and the facility's policy required adherence to such parameters. A third resident with chronic pain and polyneuropathy was prescribed senna for bowel management, with orders to hold the medication if the resident had loose stools. Despite documentation of loose stools on several days, senna was administered as scheduled, and the resident reported not ingesting the medication after realizing its purpose. The nurse admitted to administering senna despite the resident's report of loose stools, and the ADON confirmed that this was not in accordance with the physician's order. Additionally, another resident did not receive ergocalciferol as prescribed because the medication was not available in the facility at the scheduled time, which was acknowledged as a medication error by the nurse and DON.
Medication Error Rate Exceeds 5% Due to Missed and Mistimed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with two medication errors identified out of 27 opportunities, resulting in a 7.41% error rate. One error involved a resident with chronic kidney disease who did not receive their prescribed ergocalciferol supplement because the medication was not available in the medication cart or anywhere in the facility at the time of administration. The nurse responsible acknowledged that medications should be ordered in advance and available for timely administration, but this did not occur, leading to the omission. Another error occurred when a different resident received their prescribed calcium with vitamin D3 supplement at a time inconsistent with the physician's order. The medication was administered outside the facility's policy-defined 60-minute window for scheduled medication times. The nurse administering the medication recognized this as a failure to follow the '5 rights' of medication administration and the facility's guidelines for medication timing. Interviews with the Director of Nursing and the involved nurses confirmed that both incidents were considered medication errors according to facility policy and procedures. The facility's policies require medications to be administered as ordered by the physician and within a specified time frame, and both errors were attributed to failures in following these established protocols. The documentation review further supported that the medications were not administered as prescribed, confirming the deficiencies.
Unattended Medications Left on Cart by LVN
Penalty
Summary
A Licensed Vocational Nurse (LVN) was observed preparing six medications, including calcium with vitamin D, aspirin, atenolol, losartan, sennosides, and vitamin B12, for a resident. The LVN placed these medications in cups on top of a medication cart and left them unattended while entering the resident's room to take vital signs. During this time, the medication cart was not supervised, and the medications remained accessible on top of the cart. The LVN then returned to the cart, took three medication cups into the resident's room for administration, and subsequently returned for the remaining three cups to complete the administration process. During interviews, the LVN acknowledged leaving the medications unattended and stated that medications should always be supervised and securely stored. The Director of Nursing (DON) confirmed that the LVN failed to safely store and supervise the medications, noting that without supervision, other residents could potentially access the medications. Review of the facility's policy indicated that medications must be stored safely and securely, accessible only to authorized personnel, and that medication carts must be locked or attended by authorized staff.
Failure to Implement Infection Control Practices for Medical Devices and Equipment
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control practices for multiple residents. One resident with a gastrostomy tube was not placed on enhanced barrier precautions (EBP) as required by facility policy, despite the presence of an indwelling medical device. The room lacked EBP signage and a PPE supply cart, and the Infection Prevention Nurse confirmed that these should have been in place to reduce the risk of bacterial transmission. The facility's policy indicated that EBP is necessary for residents with devices such as feeding tubes, but this was not followed for the resident in question. Another deficiency was observed with a resident receiving oxygen therapy. The oxygen tubing was not labeled with the date it was last changed, and staff could not confirm when it had been replaced. Facility policy and staff interviews indicated that oxygen tubing should be changed and labeled at least weekly to prevent infection, but this was not done. In a separate instance, a different resident's oxygen tubing was not replaced weekly as required, with the tubing in use for more than three weeks, contrary to the facility's infection control protocol. Additionally, a resident's urinal was found at the bedside without a resident identifier label. Staff confirmed the urinal was not labeled, and the DON stated that labeling is necessary to prevent cross-contamination. However, the Director of Medical Records noted that there was no specific policy addressing urinal labeling. The facility's general infection prevention and control policy requires measures to prevent the development and transmission of communicable diseases, but these specific practices were not consistently implemented.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain resident dignity in two separate instances involving two residents. In the first case, a resident with a history of falls, major depressive disorder, and type 2 diabetes mellitus, who was cognitively moderately impaired and required assistance with hygiene, had an indwelling urinary catheter. During observation, it was noted that the resident's urinary catheter bag was not covered with a privacy bag, contrary to facility policy and staff statements that such coverage is required to promote dignity. Both the MDS Coordinator and Assistant Director of Nursing confirmed that the catheter bag should have been covered, and the facility's policy explicitly stated that privacy bags must be used at all times for catheter drainage bags. In the second instance, another resident with type 1 diabetes mellitus, end stage renal disease, and a below-knee amputation, who required moderate assistance for bathing, reported that staff did not knock before entering the shower room while he was showering. The resident stated that staff entered multiple times to drop off soiled linens without knocking, which he felt violated his dignity and privacy. The CNA assisting the resident confirmed that several staff members entered the shower room without knocking, and the Director of Nursing acknowledged that staff are required to knock before entering any room occupied by a resident to preserve privacy and dignity. Both incidents were found to be inconsistent with the facility's policies on promoting and maintaining resident dignity, which require staff to treat residents with respect, ensure privacy, and use privacy bags for catheter drainage. The deficiencies were identified through interviews, record reviews, and direct observation, with staff and leadership confirming the expectations and acknowledging the lapses.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident's call light was not kept within reach, as required by the facility's policy and the resident's care plan. The resident, who had a history of falls, severe cognitive impairment, and required maximal assistance for most activities of daily living, was observed asleep in bed with the call light found on the floor. This was confirmed by a Certified Nursing Assistant during the observation. The resident's care plan specifically included the intervention to keep the call light within reach and encourage its use for assistance. The Director of Nursing confirmed that call lights should be accessible to residents. The facility's policy also required staff to ensure call lights are within reach and secured as needed. The failure to keep the call light accessible represented a lack of adherence to both the care plan and facility policy.
Failure to Notify Physician of Resident's Significant Improvement in Mobility
Penalty
Summary
The facility failed to notify the primary physician of a significant improvement in a resident's condition, specifically regarding the resident's ability to perform sit-to-stand transfers using both prosthetic legs. The resident, who had a history of bilateral lower extremity amputations and was admitted with diagnoses including Type 1 diabetes mellitus, was initially assessed by physical therapy (PT) as requiring moderate to maximal assistance for transfers and was not ambulating due to safety concerns. After discharge from PT, the resident was placed on a Restorative Nursing Aide (RNA) program for sit-to-stand transfers in the parallel bars, with the care plan instructing staff to monitor for changes and refer to nursing or rehabilitation with any change in condition. Over time, the resident demonstrated significant improvement, becoming able to perform sit-to-stand transfers with minimal or no assistance and expressing a strong desire to progress to walking. Despite this improvement, the change was not documented in the medical record, nor was it reported to the charge nurse or the primary physician as required by facility policy. Interviews with staff revealed that while the improvement was verbally communicated among RNA and PT staff, it was not formally reported or documented, and the required notification to the physician did not occur. As a result of this failure to communicate and document the resident's improvement, the resident continued with the RNA program and did not receive a reassessment or further PT services that could have supported greater independence with mobility, including walking. The facility's policy required notification of the physician and consultation when there was a significant change in a resident's physical condition, but this process was not followed in this case.
Failure to Accurately Assess and Document Resident's Range of Motion Limitation
Penalty
Summary
The facility failed to accurately assess a resident's range of motion (ROM) limitations, specifically regarding the left leg, during three consecutive quarterly Minimum Data Set (MDS) assessments. Despite multiple therapy evaluations and care plans indicating a history of left femur fracture, ongoing ROM impairment, and the need for assistance with mobility and activities of daily living, the MDS assessments consistently documented that the resident had no functional ROM limitations in either leg. This discrepancy was identified through a review of therapy evaluations, care plans, and direct observation, all of which confirmed the presence of a left leg ROM limitation. The resident in question was admitted with significant medical history, including morbid obesity, a healed traumatic fracture, and a history of falls. Therapy records from both occupational and physical therapy documented the resident's need for moderate to maximal assistance with bed mobility, transfers, and lower body care, as well as specific recommendations for active and active assistive ROM exercises to both legs. Observations and interviews with staff and the resident further confirmed the left leg's reduced ROM and ongoing need for restorative interventions. Despite this clear documentation and direct evidence, the MDS assessments failed to reflect the resident's actual ROM limitations, resulting in inaccurate data being entered into the federal database. The MDS Coordinator acknowledged that the assessments were inaccurate and that the information from therapy evaluations should have been incorporated into the MDS to ensure an accurate representation of the resident's condition.
Failure to Develop Comprehensive Care Plans for Oxygen Therapy and Opioid Use
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific clinical needs. For one resident with diagnoses including atrial fibrillation and congestive heart failure, who was dependent on staff for all activities of daily living and had severely impaired cognitive skills, there was a physician's order for continuous oxygen therapy due to acute respiratory failure with hypoxia. However, upon review, staff could not locate a care plan addressing the resident's oxygen therapy, and both the MDS Coordinator and DON confirmed that a care plan should have been in place. In a separate case, another resident with chronic pain syndrome and intact cognition was receiving hydromorphone for moderate to severe pain on a regular basis, as documented in the Medication Administration Record. Despite the consistent administration of this opioid medication, there was no care plan addressing the resident's use of hydromorphone, including monitoring for adverse reactions or effectiveness. The DON acknowledged that a care plan should have been developed for this medication regimen. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes for all identified needs.
Failure to Timely Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to timely update and revise care plans for two residents, resulting in deficiencies related to individualized care. For one resident with a history of epilepsy and a physician's order for padded side rails to reduce injury risk, the care plan was not updated to include this intervention until over two months after the order was issued. The care plan for seizure disorder was only revised to include padded side rails well after the physician's directive, despite staff acknowledging that timely updates are necessary to ensure consistent implementation of safety measures. Another resident with an indwelling catheter for urinary retention had a care plan that was not reviewed or revised for more than six months, despite facility policy requiring quarterly reviews. The care plan, which included interventions to monitor for urinary tract infection and proper catheter bag positioning, was last updated in November of the previous year and not subsequently reviewed, even though the resident continued to require catheter care. Interviews with facility staff confirmed that care plans are expected to be reviewed quarterly and after any change in condition, to ensure interventions remain effective and all pertinent information is included. The failure to adhere to these review and revision schedules was acknowledged by staff, who stated that such lapses could result in inadequate care and supervision. Facility policy also mandates comprehensive, person-centered care plans that are regularly updated to reflect residents' needs as identified in assessments.
Failure to Provide Timely Medical Device Resulting in Decline in ADLs and Mobility
Penalty
Summary
A resident with a history of sepsis, falls, left knee injury requiring surgery, and major depressive disorder was admitted to the facility and required a left knee immobilizer and right CAM walker boot for safe mobility and transfers. Therapy assessments indicated the resident previously functioned independently but now required assistance for mobility and ADLs due to recent injuries. Both physical and occupational therapy documented that the left knee immobilizer did not fit properly, causing it to slide down and making transfers and ambulation unsafe. As a result, therapy sessions were halted, and the resident was unable to participate in standing activities, ambulation, or transfers out of bed. Despite physician orders for orthopedic and orthotic consultations to obtain a properly fitting knee immobilizer, there was a significant delay in acquiring the device. The resident remained in bed for 12 days, as documented by therapy and nursing staff, due to the absence of a suitable knee immobilizer. During this period, the resident did not receive therapy or assistance with transfers, and documentation indicated that transferring was not applicable or that the resident was totally dependent with at least two-person assistance. The case management team was unaware of the resident's current status and the arrival of a new immobilizer, and there was no documentation of the facility's efforts to expedite obtaining the device. Interviews with staff, the resident, and family confirmed that the resident was confined to bed and unable to participate in therapy or transfers due to the lack of a properly fitting knee immobilizer. The resident expressed feelings of sadness and depression as a result of being bedbound and unable to progress with therapy. The facility's policy required that residents' abilities in ADLs not decline unless unavoidable, but the lack of timely provision of the necessary medical device led to a preventable decline in the resident's mobility and ADL participation.
Failure to Provide Consistent Bathing Care and Document Resident Preferences
Penalty
Summary
A resident with diagnoses of morbid obesity and type 2 diabetes mellitus, who was assessed as having moderately impaired cognitive skills and requiring partial to moderate assistance with activities of daily living (ADLs), was not consistently provided with appropriate bathing care. The resident reported only receiving bed baths and not being offered showers, despite expressing varying preferences for either a shower or a bed bath. Staff did not ask the resident for her preference, and documentation was lacking regarding whether the resident was offered, received, or refused showers or bed baths on multiple days. Review of the Certified Nurse Assistants' ADL task documentation revealed that during two separate weeks, the resident received only one bed bath each week, with no documentation for the remaining days to indicate if bathing was offered or refused. The Assistant Director of Nursing confirmed that, based on the resident's functional abilities, she should be able to shower with partial assistance and that residents are to receive either a shower or bed bath twice weekly. Facility policy also required staff to assist residents with bathing to maintain proper hygiene. The lack of consistent bathing care and documentation constituted a failure to ensure the resident's personal hygiene needs were met.
Failure to Coordinate Ordered Vascular Studies and Follow-Up
Penalty
Summary
The facility failed to ensure that a resident with a history of diabetes mellitus, a foot ulcer, and a previous deep vein thrombosis (DVT) received ordered vascular studies and a follow-up appointment with a vascular surgeon. The resident was admitted with significant medical concerns, including chronic left arm swelling and pain following a DVT and removal of a peripherally inserted central catheter (PICC). The vascular surgeon ordered comprehensive venous and arterial ultrasounds of both the upper and lower extremities, with instructions for a follow-up appointment after the studies were completed. These orders were documented in the resident's medical record and care plan, which also included interventions to obtain and monitor diagnostic work as ordered. Despite these documented orders, the resident did not receive the required vascular studies or the follow-up appointment. The resident reported that he had been waiting several weeks for the studies and was unaware of the reason for the delay, noting that the staff member who previously coordinated his appointments had left. The current case manager confirmed that the need for these studies and follow-up was not communicated to her during the transition. Facility leadership acknowledged responsibility for coordinating such care and recognized the importance of the ordered tests. The facility's policy requires that residents receive care and services according to professional standards and care plans, but this was not followed in this instance.
Incorrect LAL Mattress Setting for Pressure Ulcer Management
Penalty
Summary
A resident with a history of a stage 4 pressure ulcer of the sacral region, who was dependent on staff for activities of daily living and had severely impaired cognitive skills, was admitted and readmitted to the facility. Physician orders and the resident's care plan specified the use of a low air loss (LAL) mattress for wound management, with instructions to determine and set the appropriate mattress settings based on the resident's needs. The manufacturer's guide for the LAL mattress indicated that the mattress should be set according to the patient's weight or comfort level. During an observation, the resident was found asleep in bed with the LAL mattress set to 225 lbs, despite a sticker on the mattress indicating it should be set to 87 lbs. This incorrect setting was confirmed by a Licensed Vocational Nurse, who acknowledged the discrepancy. The Director of Nursing also confirmed the importance of correct mattress settings for pressure ulcer prevention and management. The facility's policy emphasized the use of appropriate pressure-redistributing support surfaces for residents at risk or with existing pressure injuries. The failure to set the LAL mattress to the correct setting constituted a deficiency in providing appropriate pressure ulcer care.
Failure to Provide Proper Catheter Care and Positioning
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling catheters, resulting in two deficiencies. For one resident with a history of falls, major depressive disorder, and type 2 diabetes mellitus, the facility did not provide indwelling catheter care or monitoring after the resident was readmitted from the hospital. The resident's physician order summary and treatment administration records showed no evidence of catheter care or monitoring after the readmission, and there were no physician orders for catheter care in the medical record. The assistant director of nursing confirmed that catheter care was not reinstated upon the resident's return from the hospital, despite facility policy requiring catheter care every shift and as needed. For another resident with urinary retention and type 2 diabetes mellitus, the facility failed to ensure proper positioning of the urinary catheter collection bag. During observation, the resident was seen sitting in a wheelchair with the catheter collection bag placed at the same level as the bladder, rather than below it as required. The registered nurse present confirmed that the collection bag should be positioned below the bladder to prevent backflow of urine, in accordance with facility policy and the resident's care plan. Both deficiencies were identified through interviews, record reviews, and direct observation. The facility's own policies and procedures, as well as the residents' care plans, specified the required catheter care and positioning, but these were not followed in the cases observed.
Failure to Document Nonpharmacological Pain Interventions Prior to PRN Opioid Administration
Penalty
Summary
The facility failed to ensure that nurses documented the use of nonpharmacological interventions prior to administering as-needed (PRN) hydromorphone to a resident with a left rib fracture. The resident, who had intact cognition and required maximal assistance with most activities of daily living, had a physician's order specifying that nonpharmacological interventions should be attempted before administering opioid medication for severe pain. However, review of the Medication Administration Record showed that the resident received hydromorphone on multiple occasions, and there was no documentation indicating that nonpharmacological interventions were attempted prior to medication administration. During interviews, the MDS Coordinator was unable to locate any documentation of nonpharmacological interventions before the administration of hydromorphone, and the Director of Nursing acknowledged the importance of such interventions to avoid unnecessary medication. The facility's pain management policy, which was current at the time, required the use of various nonpharmacological strategies before medicating for pain, but these were not documented as being attempted for the resident in question.
Failure to Act on Consultant Pharmacist's Recommendations for PRN Constipation Medications
Penalty
Summary
The facility failed to act upon recommendations from the Consultant Pharmacist regarding a resident's medication regimen for constipation. The resident, who had diagnoses including type 2 diabetes mellitus, major depressive disorder, and insomnia, was dependent on staff for several activities of daily living and had moderately impaired cognitive skills. The resident's physician orders included multiple PRN medications for constipation, such as bisacodyl suppository, lactulose, magnesium citrate, magnesium hydroxide, and polyethylene glycol, as well as a scheduled senna tablet. The Consultant Pharmacist's monthly medication regimen review specifically recommended that all PRN orders for constipation be reviewed and that the physician's orders specify the sequence in which these medications should be administered. Despite this recommendation, facility staff did not review the resident's PRN constipation medications or ensure that the physician's orders included the required sequencing. The Assistant Director of Nursing confirmed that the recommendation was received but not acted upon, acknowledging that licensed staff did not follow up as required by facility policy. The facility's policy states that staff must act upon all recommendations from the Consultant Pharmacist, but this procedure was not followed in this instance.
Failure to Ensure Timely Administration of Antidepressant Medication
Penalty
Summary
Resident 89, who was admitted with diagnoses including depression and a history of cerebrovascular accident, was prescribed Paxil 40 mg daily for depression. According to the resident's medication administration records (MAR) and pharmacy delivery records, the facility failed to ensure the resident received Paxil from 5/31/2025 until 6/04/2025. The pharmacy delivery records confirmed that there was no Paxil delivered to the facility to cover these dates, resulting in missed doses for the resident. Interviews with the resident, nursing staff, and the Director of Nursing (DON) revealed that the medication was not available during this period, and the staff had to request a new supply from the pharmacy. The resident reported a time when the facility ran out of Paxil, and the DON confirmed the medication was not delivered in time for scheduled administration. The MAR indicated that the medication was not administered during the gap, and the pharmacy confirmed the absence of delivery for the missing days. Facility policies required timely reordering of medications and immediate action when medications were unavailable, including notifying the physician and monitoring the resident. However, these procedures were not followed, as there was no evidence of timely reordering or alternative arrangements during the period when Paxil was unavailable. This resulted in the resident missing several doses of a significant medication prescribed for depression.
Failure to Provide Ongoing PT for Resident with New Prosthetics
Penalty
Summary
A deficiency occurred when the facility failed to provide ongoing physical therapy (PT) interventions for a resident with bilateral leg amputations and new prosthetic legs, despite documented improvement and continued need for therapy. The resident, who had a history of Type 1 diabetes mellitus and both right above-knee and left below-knee amputations, was initially referred to PT for assessment and training in sit-to-stand transfers and ambulation with new prosthetics. The PT evaluation and subsequent treatment notes showed the resident required varying levels of assistance for transfers and ambulation, but demonstrated progress over six PT sessions, improving from maximal to moderate assistance for both sit-to-stand transfers and walking in parallel bars. Despite this progress, PT services were discontinued after only six sessions, with the discharge summary citing a decision made in accordance with the physician or case manager, and referencing the resident's health insurance coverage as a limiting factor. The discharge summary recommended that the Restorative Nursing Aide (RNA) continue sit-to-stand training, but did not include further gait training or ambulation, which the resident had not yet mastered. Interviews with the resident, therapy staff, and the interim director of rehabilitation confirmed that the resident was motivated to walk, had requested more therapy, and that the therapy team believed the resident could have benefited from additional PT to reach a higher level of function. However, there was no documentation that the therapy department discussed the resident's progress or the possibility of extending therapy services with the physician prior to discharge. Observations of RNA sessions showed that the resident was able to perform sit-to-stand transfers with minimal assistance and was eager to progress to walking, but the RNA sessions were limited in scope and duration. The facility's policies required that therapy services be provided to restore residents to their highest level of function, but the lack of communication with the physician and failure to advocate for continued therapy services resulted in the resident being discharged from PT before achieving the goal of independent ambulation with prosthetics.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident, the nursing staff documented the administration of wound care treatment to the left knee prior to actually providing the treatment. The Treatment Nurse stated that Betadine was applied and the dressing was changed at the end of the day, but the Treatment Administration Record (TAR) showed documentation of the treatment earlier in the day. The nurse admitted to documenting the treatment as completed before actually performing it, which was not consistent with professional standards and could result in missed treatments. The Director of Nursing confirmed that documentation should occur after the treatment is provided and acknowledged that the TAR was not accurate, which could have led to missed care. For another resident, the facility did not develop a complete Change in Condition (COC) Evaluation form after the resident experienced a fall. The COC evaluation form was marked incomplete and could not be reviewed by the surveyor. The Assistant Director of Nursing confirmed that the charge nurse did not sign and complete the form, and stated that licensed staff are required to develop a complete and accurate evaluation after a resident's change of condition. The incomplete documentation meant that the resident's medical record was not valid and could result in the resident not receiving appropriate care due to inaccurate information. Both deficiencies were identified through interviews, record reviews, and observations. The facility's policies required that all services provided be documented in the resident's medical record in accordance with state law and facility policy, and that documentation be factual and completed at the time of service or no later than the end of the shift. The failures in documentation for both residents were not in accordance with these policies and accepted professional standards.
Failure to Protect Residents from Verbal Abuse by Staff and Peers
Penalty
Summary
The facility failed to protect residents from verbal abuse in two separate incidents involving both staff and resident-to-resident interactions. In the first incident, a resident with a history of confirmed adult physical abuse and moderate cognitive impairment reported a verbal altercation with a Certified Nursing Assistant (CNA) after the CNA removed the resident's dinner tray without consent. Both the resident and the CNA admitted to exchanging profanities, and the CNA acknowledged responding to the resident's remarks with offensive language. The Director of Nursing (DON) confirmed that staff should not use profane language toward residents and should maintain professionalism, while the Administrator (ADM) stated that the CNA's actions met the facility's definition of verbal abuse as outlined in their policy. In the second incident, a resident with mild cognitive impairment and total dependence for activities of daily living was subjected to repeated offensive and discriminatory language by a roommate who had severe cognitive impairment. Multiple CNAs reported hearing the roommate use profanities and discriminatory remarks directed at the resident, particularly regarding the resident's race and choice of television programming. The Social Services Director and the DON both acknowledged that such language constitutes verbal abuse and can cause psychosocial distress. The ADM confirmed that the roommate's words met the facility's definition of verbal abuse and should have been reported to supervisors and external entities. Both incidents were substantiated through interviews with residents, staff, and review of facility records and policies. The facility's policy defines verbal abuse as willful use of disparaging or derogatory terms, regardless of the recipient's ability to comprehend, and requires the prevention and prohibition of such abuse. The failure to prevent and address these incidents resulted in residents being subjected to verbal abuse by both staff and another resident.
Failure to Timely Report and Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure regarding abuse, neglect, and exploitation by not reporting an allegation of verbal abuse from one resident to another to the required authorities within the mandated timeframe. Specifically, a resident with mild cognitive impairment and total dependence on staff for activities of daily living reported that his roommate had repeatedly yelled at him, used offensive language, and made discriminatory remarks about his race. Multiple certified nursing assistants (CNAs) confirmed hearing these profanities and discriminatory remarks on several occasions, particularly when the resident was watching television. Despite this, none of the CNAs reported the incidents to supervisory staff, assuming that everyone was already aware of the behavior. The Social Services Director (SSD) and other facility leadership, including the Director of Nursing (DON) and the administrator, were unaware of the ongoing verbal abuse until it was brought to their attention during the survey. Interviews revealed that staff did not follow the facility's policy, which requires immediate reporting of all alleged violations of the abuse policy to the administrator, state agency, and other required agencies, no later than two hours after the allegation is made. The SSD and administrator acknowledged that the language used constituted verbal abuse and should have been reported and investigated according to policy. A review of the facility's policy confirmed that verbal abuse includes disparaging and derogatory communication directed at residents or within their hearing, regardless of their ability to comprehend. The policy also specifies that all alleged violations must be reported promptly to ensure resident protection. The failure to report the abuse resulted in unidentified abuse within the facility and a lack of protection for the affected resident.
Failure to Document Discontinuation of Hemodialysis and Permcath Removal
Penalty
Summary
The facility failed to document a physician's order to discontinue hemodialysis treatment and to send a resident for permcath removal, as required for a resident with end stage renal disease. The resident, who was cognitively impaired and dependent on staff for daily care, had an existing order for hemodialysis three times weekly. On review, it was found that a Dialysis Visit Note indicated an order to discontinue hemodialysis and arrange for permcath removal, but this was not documented in the resident's clinical record. The registered nurse involved acknowledged receiving the information from the dialysis center and discussing it with the nurse practitioner, but did not document the conversation or obtain the necessary order from the primary provider. The delay in obtaining and documenting the order for permcath removal resulted in the resident being sent for the procedure at a later date. The facility's policy required care and treatment to be consistent with professional standards, physician orders, and the resident's care plan, but these standards were not met in this instance. The lack of documentation and delay in action had the potential to result in health complications, including the risk of infection at the permcath site.
Failure to Conduct Trauma Assessments for Residents
Penalty
Summary
The facility failed to conduct trauma assessments for three sampled residents, each with significant medical and psychosocial histories. For one resident, the admission record showed diagnoses including type 2 diabetes, dementia, and chronic pain, with documentation of fluctuating decision-making capacity and moderate cognitive impairment. After an incident where the resident reported being struck, further review and family input revealed the report was likely a trauma response triggered by pain and past experiences. Despite these indicators, there was no documented trauma assessment in the resident's records. A second resident, with a history of diabetes with neuropathy and suicidal ideations, also exhibited fluctuating capacity for decision-making and moderate cognitive impairment. This resident required substantial assistance with daily activities. Review of clinical records confirmed that no trauma assessment was documented for this individual, despite their complex psychosocial and medical needs. A third resident, admitted with a recent fracture and cerebral infarction affecting the dominant side, also had moderate cognitive impairment and required significant assistance with personal care. Again, no trauma assessment was found in the records. Interviews with facility staff revealed confusion regarding responsibility for trauma assessments, with the Social Services Director and Director of Nursing each indicating it was the other's responsibility. Facility policy required trauma-informed care and culturally competent services, but these were not implemented as trauma assessments were not completed for the residents involved.
Failure to Document Wound Care in Medical Record
Penalty
Summary
The facility failed to document wound care treatment provided to one resident in the Treatment Administration Record (TAR) as required by professional standards and facility policy. The resident was admitted with multiple diagnoses, including type 2 diabetes, alcoholic cirrhosis of the liver, dysphagia, chronic kidney disease, an unstageable pressure ulcer of the sacrum, and a gastrostomy tube. Physician orders directed daily wound care for both the sacrum and gastrostomy tube site. However, review of the TAR for the relevant period showed that documentation of these treatments was left blank for several days. Interviews with the licensed vocational nurses responsible for the resident's care confirmed that the treatments were provided as ordered, but the nurses did not document the completion of these treatments in the TAR. The Director of Nursing also acknowledged that documentation should have occurred after the treatments were provided, in accordance with facility policy, which requires that care and services be documented at the time of service or by the end of the shift.
Failure to Follow Care Plan for Side Rail Use
Penalty
Summary
A deficiency was identified when staff failed to implement a patient's care plan as ordered. The patient, who was legally blind, dependent on staff for activities of daily living, and at high risk for falls, had a care plan and physician order specifying that one fourth side rails should be up while in bed to assist with positioning and turning. During an observation, the patient was found lying in bed with the bed in the highest position and the left one fourth side rail down, contrary to the care plan and physician order. Certified Nursing Assistant 2 confirmed that the side rail should have been up and that the patient required it for mobility and fall prevention. Further interviews with nursing staff confirmed that beds should not be left in a high position unattended and that the care plan required the side rail to be up while the patient was in bed. Review of facility policy indicated that comprehensive care plans with patient-specific interventions must be implemented. The failure to follow the care plan and physician order for side rail use constituted the deficiency.
Plan Of Correction
C835: T22 DIV5 CH3 ART3- 72311(a)(2) Nursing Service - General Corrective action for resident found to have been affected by this deficiency: On 3/10/2025, both rails were verified to be up by DSD for resident 5. Identify any other residents who may have been affected by the deficient practice: On 3/10/25, ADONS and DSD performed rounds of the entire facility to ensure that any patients who had orders for side rails were following MD orders and adhering to the care plan. There were no other issues identified. Measures that will be put into place to ensure that this deficiency does not recur: Beginning 3/10/2025, DSD initiated in-servicing of CNA and licensed nursing staff regarding ensuring side rails are being utilized in accordance with physician's orders and patient plan of care. (To continue page 3 of 25) Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: Beginning 3/10/25, DSDS will perform weekly rounds of all in-house patients to ensure that if side rails are ordered, they are in place as per MD orders and plan of care. These audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by DSD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25
Insulin Administered Too Early Before Meal
Penalty
Summary
A patient with diabetes mellitus, who was cognitively intact and required some assistance with daily activities, was prescribed insulin lispro to be administered subcutaneously 15 minutes before meals and at bedtime, according to a sliding scale based on blood glucose levels. On the day in question, the patient received 8 units of insulin lispro at 4:00 p.m. for a blood sugar reading of 301 mg/dL, prior to the scheduled dinner. The patient's care plan specified that diabetes medication should be given as ordered by the physician. Observation and interviews revealed that the insulin was administered significantly earlier than the prescribed time, as the patient had not yet received the dinner meal more than an hour after the injection. The nurse who administered the insulin stated that it could be given up to an hour before the meal and did not provide a snack to the patient before dinner, citing being busy with other tasks. Facility policy required medications to be administered as ordered and in accordance with manufacturer specifications, which was not followed in this instance.
Plan Of Correction
C900: T22 DIV5 ART3-72313(a)(2) Nursing Service - Administration of Medication Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, DON assessed Patient 7 for any adverse reactions related to the early administration of insulin lispro. There was no change in condition noted. Identify any other residents who may have been affected by the deficient practice. On 3/12/2025, MRD audited the last 7 days of insulin administration to ascertain if any other patients had been given insulin before it was due. There were no other issues identified. Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, in-servicing of licensed nurses regarding the proper timing and administration of insulin was initiated. (To continue page 5 of 25) continued Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/12/2025, MRD will spot check insulin administrations of 5 patients per week to ensure they are not being administered before they are due. These weekly audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed. 04/03/25 C 900
Late Administration of Scheduled Medications
Penalty
Summary
A deficiency was identified when a registered nurse administered a resident's scheduled 9 a.m. medications approximately one hour later than the prescribed time. The medications included aspirin, Zyprexa, vitamin D, and Keppra, which were observed being given at 10:57 a.m. The nurse confirmed that these were the resident's 9 a.m. medications and acknowledged they were administered about an hour late. The facility's policy and the Director of Nursing both stated that medications should be administered within one hour before or after the scheduled time unless otherwise ordered by a physician. The resident involved had a history of hypertension and traumatic brain injury, and required moderate assistance with certain activities of daily living, but had intact cognitive skills. The late administration of medications was observed during a medication pass, and the facility's records and staff interviews confirmed the deviation from the required medication administration schedule.
Plan Of Correction
C945: T22 DIV5 CH3 ART3-7231(a)(6) Nursing Service - Administration of Medication. Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, RN assessed Patient 2 for any adverse reactions related to the late administration of morning medications. There was no change in condition noted. On 3/10/2025, RN notified the attending physician of Patient 2 of the late administration with no new orders obtained. (To continue page 8 of 25) Identify any other residents who may have been affected by the deficient Practice. On 3/12/2025, audited the last 7 days of medication administration to ascertain if any other patients had been administered routine medications late. There were none other issues identified. Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, DSD initiated in-servicing of licensed nurses regarding the proper timing and administration of medications. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/12/2025, MRD will spot check medication administrations of 5 patients per week to ensure they are not being administered after they are due. (To continue page 9 of 25) These weekly audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25 C1115: T22 DIV5 CH3 ART3-72315(m) Nursing Service - Patient Care Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, RN placed the call light in reach of Patient 1. On 3/10/2025, RN answered the call light and attended to the needs of Patient 4. Identify any other residents who may have been affected by the deficient Practice. On 3/10/2025, ADONs and DSD made rounds of all in-house patients to ensure all call lights are in place and within reach. There were none other issues identified. On 3/10/2025, ADONs and DSD made rounds of all units to ensure staff is not walking past call lights that are engaged and ensuring that all call lights have been answered. There were none other issues identified. (To continue page 11 of 25)
Failure to Ensure Call Light Accessibility and Prompt Response
Penalty
Summary
The facility failed to ensure that patient call lights were accessible and answered promptly for two patients. For one patient with severe cognitive impairment, muscle weakness, and a history of traumatic brain injury, the call light was observed on the floor under the headboard, out of the patient's reach while the patient was lying in bed. This was confirmed by a registered nurse, who acknowledged that the call light was unreachable and that this could delay the patient's care needs. Facility policy requires that call lights be within reach and accessible to patients at all times. For another patient with a history of falls, reduced mobility, and a recent femur fracture, the call light was activated while the patient needed assistance with toileting. A certified nursing assistant walked past the room, saw the lit call light, but did not respond because the patient was not assigned to her that day. The CNA later confirmed she should have checked on the patient regardless of assignment. Facility policy states that any staff member who sees or hears an activated call light is responsible for responding. These failures had the potential to delay the provision of services and result in unmet patient needs.
Plan Of Correction
Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/11/2025, DSD initiated in-servicing for CNA and licensed nursing staff regarding ensuring call lights are in place and in reach of patients as well as ensuring that call lights are not passed in the hallway without answering. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/11/2025, DSDs will make weekly rounds of all patient rooms to ensure call lights are in place and within reach as well as that staff is not walking past call lights that are engaged in the hallways. These rounds will continue for 1 month or until substantial compliance is obtained. Any ongoing noncompliance will be reported by DSD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25 C1115
Failure to Use PPE During Contact Isolation Precautions
Penalty
Summary
Nursing staff failed to wear required personal protective equipment (PPE), specifically gloves and a gown, when delivering and removing a lunch tray for a patient who was on contact isolation due to an infectious disease. Observation showed a Certified Nurse Assistant (CNA) entering the patient's room without donning PPE, and later accepting an empty lunch tray from the patient without gloves. The CNA acknowledged this was a breach of the facility's contact isolation protocol, which is intended to prevent the spread of infection. The patient involved had been admitted with diagnoses including shortness of breath and cellulitis of the back, and required supervision for several activities of daily living. Facility policy, as well as statements from the Director of Nursing (DON), confirmed that staff are required to wear full PPE when entering the room of a patient on contact isolation, including when handling food trays. The facility's policy also indicated that PPE should be readily available near the entrance to the patient's room and must be donned before or upon entry.
Plan Of Correction
C1245: T22 DIV5 CH3 ART3-72321(a) Nursing Service - Patients with infectious disease Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, CNA 1 was provided 1:1 education regarding transmission-based precaution requirements and encouraged to perform prompt hand hygiene. Identify any other residents who may have been affected by the deficient practice. On 3/10/2025, DSD and IP made rounds of all isolation rooms in the facility to ascertain if there were any other staff members entering contact isolation rooms without proper PPE. There were no other issues identified. Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, IP initiated in-servicing to CNA and licensed nursing staff regarding proper PPE use as indicated when delivering or picking up meal trays. (To continue page 15 of 25) Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/10/2025, IP will perform weekly rounding of all isolation rooms to ascertain if staff is utilizing PPE as indicated. These rounds will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by IP nurse at the monthly QA meeting. Date of corrective action would be completed. 04/03/25 C1245
Failure to Provide Prescribed Seizure Medications as Ordered
Penalty
Summary
The facility failed to ensure that prescribed seizure medications, Lacosamide (Vimpat) and Clobazam, were available and administered as ordered for a patient diagnosed with epilepsy. Multiple instances were documented where these medications were not available in the facility, as evidenced by medication administration records (MAR), controlled drug records (CDR), and nursing progress notes. Specific dates were noted where the medications were not present, and nurses documented the unavailability in the patient's records, with no signatures on the CDR to indicate administration. Interviews with the patient confirmed that there were multiple days when the prescribed medications were not received. Nursing staff also acknowledged that there were times when the medications were not available, and one nurse admitted to incorrectly documenting that a medication was given when it was not, due to its unavailability. The Director of Nursing confirmed the absence of the medications on the specified dates and acknowledged that the medications were not present in the facility to be administered as prescribed. A review of facility policies indicated that there should be a systematic approach to ensure timely acquisition and administration of medications, but these procedures were not followed in this case. The failure to provide the necessary medications as ordered was substantiated by direct observation, interviews, and record reviews, demonstrating a breakdown in the facility's pharmaceutical service requirements.
Plan Of Correction
C1930: T22 DIV5 CH3 ART3- 72355(a)(1)(D) Pharmaceutical Service - Requirements Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, DON ensured the Lacosamide and Clobazam was available for use for Patient 8. Identify any other residents who may have been affected by the deficient practice. On 3/12/2025, MRD performed an audit of all patients on seizure medications to ensure that the medications were available for use in the medication carts. There were no other issues identified. (To continue page 17 of 25) Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, DSD initiated in-servicing of licensed nursing staff regarding prompt ordering of medications and strategies for follow-up with pharmacy and physician to ensure prompt delivery. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/12/2025, MRD will perform an audit of all patients on seizure medications to ensure that the medications are available for use in medication carts. These audits will continue weekly for 1 month. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25
Failure to Document Pain Medication Administration on MAR
Penalty
Summary
Licensed nurses at the facility failed to properly document the administration of pain medication for a patient with chronic pain syndrome. Specifically, on two occasions, Norco was removed from the medication cart and signed out on the Controlled Drug Record (CDR) for the patient, but there was no corresponding entry on the Medication Administration Record (MAR) to indicate that the medication was administered. The MAR is required to be signed after medication administration to ensure accurate documentation and assessment of the patient's pain and response to treatment. During interviews, both the licensed nurse involved and the Director of Nursing confirmed that the established process requires signing the CDR, administering the medication, and then signing the MAR. The absence of documentation on the MAR meant that there was no record of the patient's pain assessment or the effectiveness of the pain medication for those times. Facility policy also requires the MAR to be signed after medication administration, and the CDR, in conjunction with the MAR, serves as the official record for controlled substance administration.
Plan Of Correction
C4975: T22 DIV5 CH3 ART5-72543(f) Patients' Health Records Corrective action for resident found to have been affected by this deficiency: On 3/11/2025, DON provided 1:1 in-servicing to LVN 4 regarding proper PRN controlled medication administration documentation and accountability. Identify any other residents who may have been affected by the deficient practice: On 3/12/2025, MRD audited the last 7 days of PRN Norco administration for in-house patients to ensure all documentation is complete. There were no other issues identified. Measures that will be put into place to ensure that this deficiency does not recur: Beginning 3/11/2025, DSD initiated in-servicing for licensed nursing regarding proper documentation and signing for administration of controlled medications. (To continue) Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: Beginning 3/12/2025, MRD will perform weekly audits of the last 7 days of PRN Norco administration for in-house patients to ensure all documentation is complete. These audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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