The Meadows On Sunset Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 5154 Sunset Blvd, Los Angeles, California 90027
- CMS Provider Number
- 056056
- Inspections on file
- 85
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 49 (1 serious)
Citation history
Health deficiencies cited at The Meadows On Sunset Post Acute during CMS and state inspections, most recent first.
The facility failed to maintain dignity and privacy for multiple residents during ADL care, mealtime assistance, and catheter care. CNAs left privacy curtains partially open during morning care, exposing a resident’s undressed body and leaving another resident’s care area open. Two CNAs were also observed standing over residents while assisting with lunch instead of sitting at eye level. In addition, two residents’ urinary catheter drainage bags were observed uncovered without dignity bags, and staff stated the bags should be covered to protect privacy and dignity.
Call lights were not kept within reach for five residents with fall risk, cognitive impairment, and varying levels of assistance needs. Staff observed call lights on the floor, under mattresses, next to pillows, or dangling out of reach in residents’ rooms. CNA, LVN, RN, and DON interviews confirmed the call lights were not accessible and that staff were responsible for keeping them within reach per the facility’s call light policy.
The facility failed to manage physical restraint use appropriately for three residents. One resident’s bed against the wall was not reassessed on a quarterly basis, another resident’s bed was placed against the wall without a physician order, and a third resident had wedge pillows tucked under the fitted sheet on both sides of the bed even though staff said the resident could not remove them and no physician order was in place. Staff and the DON acknowledged the bed placement and pillow use were considered restraints when they restricted movement.
Incomplete Care Plan for Indwelling Urinary Catheter Management: A resident with an indwelling Foley catheter, BPH, and obstructive uropathy had a care plan that did not include interventions for catheter dislodgement, physician notification, securement device use, or the ordered 30-day catheter change schedule. During observation, the resident reported the catheter had come out and been replaced, the drainage bag had been changed, and the securement device had been absent for about a month. RN confirmed the tubing and bag were not dated and that the resident did not have a securement device in place, while the DON stated the care plan should address catheter-related monitoring and interventions.
A facility failed to keep resident rooms free of accident hazards when floor mats were not properly positioned and ordered safety devices were not in place. One resident’s mat was partly under the bed with a bed wheel on top of it, two residents had bedside tables placed on top of their mats, and another resident with seizure precautions did not have the ordered floor mat or padded siderails in place. Staff and the DON stated the mats were intended to reduce injury and should not have objects on them or be placed under the bed.
The facility failed to provide appropriate catheter care and UTI prevention for multiple residents. A resident with a Foley catheter had the wrong catheter size in place, no date on the catheter or drainage bag, and no securement device, while two other residents had unlabeled urinals and another resident’s catheter tubing was coiled rather than kept straight. Record review also showed two residents did not have documentation that their Foley catheters were changed every 30 days as ordered, and staff confirmed the missing labels and missed catheter-change documentation.
A survey found that bed rail use was not properly documented for three residents. Staff observed bilateral 1/2 rails or grab bars in use, but the records showed missing or mismatched physician orders, incomplete or outdated informed consent, bed rail assessments for different rail types, and care plans that did not match the devices actually being used. The residents had significant mobility and cognitive impairments, and staff confirmed the documentation did not align with the bed rail devices in use.
Failure to Rotate Insulin Injection Sites: Two residents with DM received insulin without proper rotation of subcutaneous injection sites. One resident on insulin glargine had repeated injections in the same abdominal quadrants, and the RN and DON both stated the sites were not rotated and that this was a medication error. For the other resident, the DON stated insulin lispro and Lantus sites were not rotated, contrary to facility policy and manufacturer guidance to rotate sites to reduce lipodystrophy and support proper absorption.
Unlabeled and undated food items were found in the kitchen walk-in refrigerator and the resident refrigerator. The kitchen had containers of mandarin oranges, plates of lettuce, tomato, deli meat, and boiled eggs, and raw brussels sprouts with no content, received, or prep dates; a pan of fruit cocktail was also kept beyond the facility’s 7-day limit. In the resident refrigerator, multiple food items including a tuna salad sandwich, frosted cake, frozen dinners, ice cream, and chocolates lacked resident identifiers and open or receive dates, and the IP could not confirm ownership of one item.
Infection prevention and control failed when three linen carts had torn, ripped, and holed covers that exposed clean linens, and clean sheets and blankets were observed touching the floor during folding in the laundry area. CNAs said the damaged carts came from laundry and had not been reported, while the LS, ED, and DON acknowledged the carts and linens were not maintained in a sanitary condition. The facility also had an outdated employee COVID-19 vaccination policy that still required staff to be fully vaccinated or up to date, even though the IP and DON stated current practice no longer required vaccination.
Failure to Communicate Resident Visitation Restriction Request: A resident with dementia and no decision-making capacity had a family representative request that no visitors be allowed without the representative present. The BOM forwarded the request to the SSD, but the DON and other staff stated they were unaware of any visitation restriction, and the request was not documented or communicated to all staff as described in the report.
Failure to Deliver Resident Mail on Saturdays: Three residents who had capacity to make decisions stated they received mail on weekdays but not on Saturdays. The BOM, AD, receptionist, and DON all confirmed that Saturday mail was held until Monday because the business office was closed, despite the facility policy stating residents have the right to send and receive mail and to receive letters, packages, and other materials delivered to the facility.
Incomplete Advance Directive Acknowledgement Documentation: The facility failed to fully document two cognitively intact residents’ rights information regarding advance directives. For both residents, the AHCD forms showed they received information, but the sections indicating whether they had an advance directive, did not have one, or were offered help to complete one were left blank. SSD and DON stated the forms were incomplete and did not clearly reflect the residents’ choices.
A resident with CKD, DM, and HTN, and intact cognition, was found with a broken closet drawer in the room that had been unusable for about two months. Personal belongings were observed on the bed, and the drawer had a broken bottom. The MA and DON stated that broken furniture should be addressed promptly, and that nonfunctioning furniture can affect a resident's dignity, ability to store belongings, mood, and psychosocial wellbeing.
PASRR screening was not accurately completed for a resident admitted with schizophrenia. The prior Level I indicated a serious mental disorder and the Level II was closed because SMI was not found, with instructions to submit a new Level I to reopen the case. Facility staff, including the MDSC, SSD, and DON, acknowledged the discrepancy between the PASRR and the admission records/H&P, but a new Level I was not submitted.
Failure to Develop Comprehensive Care Plan for Schizophrenia: A resident with schizophrenia, paraplegia, and generalized muscle weakness had intact cognition and needed assistance with ADLs, but the care plan did not address the schizophrenia diagnosis. RN and DON interviews confirmed no comprehensive care plan had been developed and implemented for the resident’s mental health needs, despite facility policy requiring timely person-centered care planning with measurable objectives and timeframes.
A resident with moderate hearing difficulty and diagnoses including Huntington disease, hemiplegia, and hemiparesis was unable to hear questions during interviews, and staff were unable to communicate effectively using slower speech and louder volume. No communication board or other alternative communication tools were present in the resident’s room, and staff confirmed that such tools were not available despite the facility policy calling for adaptive communication techniques such as communication boards or writing materials.
Failure to Provide Routine Nail Care and Grooming: A resident with DM, peripheral vascular disease, atrial fibrillation, and a right foot amputation required substantial/maximal assistance with several ADLs and had a care plan for help with personal hygiene, including grooming. Staff observed the resident with long fingernails and visible debris under both hands, and CNA, RN, and DON interviews confirmed that CNAs and licensed staff were responsible for routine grooming and nail care.
Low Air Loss Mattress Not Set According to Resident Weight: A resident with hemiplegia, severe cognitive impairment, incontinence, and risk for pressure injuries had an order for a low air loss mattress and treatment for a coccyx abrasion, but the mattress was observed set at 80 instead of the weight-based setting. An LVN, RN, and DON all stated the mattress should be set according to the resident’s weight, and the DON stated the facility’s pressure injury prevention guideline and the mattress user manual were not followed.
Unlabeled enteral water flush bag. A resident with a GT, DM, and CKD had an order for enteral water flush via pump, but staff observed the water flush bag hanging without the rate of infusion labeled. An LVN, RN, and DON all stated the rate should be on the bag for accurate handoff and to verify the current order; the DON noted the missing label could potentially cause under or overhydration.
A resident with a midline catheter had an IV dressing on the right upper arm that was dated beyond the weekly change interval. RN and DON stated the date reflected the last dressing change and that the dressing was overdue, while the facility policy required PICC/midline/CVAD dressings to be changed weekly or if soiled.
Unsafe oxygen tubing handling was observed for two residents. One resident with chronic respiratory failure, OSA, and morbid obesity had oxygen tubing coiled at the foot of the bed with most of it touching the floor and disconnected from the resident. Another resident with gangrene, CHF, and DM had oxygen tubing touching the floor, touching the trash can, and placed under the bedside table. Staff stated the tubing should not be on the floor or in contact with environmental objects because of infection prevention and possible interruption of oxygen delivery, and the DON stated the facility’s Oxygen Administration policy was not followed.
An LPN administered PRN acetaminophen to a resident with leg pain without verifying identity or assessing the pain level. The resident’s OSR ordered acetaminophen only for pain 1-6/10, but the resident reported 8/10 pain, and the LPN acknowledged the medication should not have been given without further assessment and that non-pharmacological measures or provider notification were indicated.
A resident with Huntington disease and right-sided weakness had documented hearing difficulty on the MDS and could not hear questions during interviews, yet weekly nursing assessments recorded adequate hearing. Staff stated the resident had hearing impairment and an ENT consult had been ordered for hearing loss, but the care plan did not address impaired hearing or communication needs, and no communication board or other alternative tools were present in the room.
Incomplete Hospice Documentation and Missed Visit Frequencies A resident with pancreatic cancer, bone cancer, and CKD 3B was on hospice with DNR and comfort-care orders, but the hospice binder was incomplete and did not contain the physician’s visit-frequency order when reviewed by the SSD. The resident’s hospice records showed missing signatures and visit notes, and several weeks reflected fewer RN, SW, CHAP, and HHA visits than listed on the VFG. The SSD stated he could not verify whether the ordered hospice visits were complete, and the DON stated the hospice binder should have contained the physician’s order, signatures, and visit notes to show hospice care was provided as ordered.
Failure to Document Reason for Continued ATB Use: A resident with osteomyelitis, a UTI, ESBL, and a diabetic foot infection had orders for levofloxacin, ertapenem, and vancomycin. Infection screening and ATB time-out forms showed no fever or current infection symptoms, and the physician was notified and said to continue the ATB regimen, but the reason for continuing therapy was not documented as required by the facility’s ATB stewardship policy.
Bed Controller Found in Disrepair: A resident with dementia, impaired cognition, and extensive ADL dependence had a bed controller observed with a peeling touch pad cover and exposed wires on the cord covered with black tape. An LVN confirmed the device was not functioning properly when the bed required multiple presses of the up button before moving, and both the LVN, RN, and DON stated the equipment was in disrepair and should have been reported for replacement.
Surveyors found that bathroom call lights were not functioning in three residents’ rooms. One resident with CHF, chronic kidney disease, muscle weakness, and lack of coordination, and another with peripheral vascular disease and muscle spasms, both cognitively intact and needing staff assistance or supervision for toileting-related tasks, could not reliably activate the bathroom call light indicators outside their rooms. A third cognitively intact resident with heart failure, anxiety disorder, muscle weakness, and hip pain, who required moderate assistance with toileting and transfers, also had a nonfunctional bathroom call light. A CNA reported a prior resident complaint about a malfunctioning call light and could not recall reporting it, while the Environmental Director acknowledged no documented system-wide functional checks and suggested a loose wiring connection as a potential cause. The DON and Environmental Director stated that all rooms should have functional call lights and that nonfunctional bathroom call lights could delay care and increase fall risk, contrary to facility policy requiring accessible and properly reported call system issues.
A resident with dementia, CKD stage 4, and dependence on renal dialysis was readmitted after a change in dialysis access from an AV fistula to a left upper chest port catheter. Despite severely impaired cognition and dependence on staff for most ADLs, the care plan was not updated to include person-centered interventions, measurable objectives, or timetables for care and monitoring of the new port catheter. An RN and the DON both acknowledged that the care plan failed to address the accurate dialysis access site and that it was not complete or person-centered, contrary to the facility’s Comprehensive Care Plans policy requiring comprehensive care plans to meet identified medical and psychosocial needs.
Surveyors found that emergency medication kits were not consistently checked and contained expired medication, and that medication disposition procedures were not followed. An IM e-kit contained expired bacteriostatic water, and staff could not produce e-kit logs for any of the three nurse stations or show that the 15 e-kits were checked each shift. A resident’s medications remained stored in a medication room long after discharge, exceeding the facility’s 90-day destruction timeframe. Medication disposition logs at two nurse stations showed drugs documented as destroyed without a second nurse witness signature, and some medications were recorded as discarded in a trash bin instead of an approved waste management system, contrary to facility policy.
A resident with multiple fractures and cognitive capacity experienced a fall, but staff did not complete a post-fall assessment, notify the physician, or initiate a Change of Condition form as required. The facility also failed to obtain physician orders for the resident's wrist splint care and did not coordinate therapy sessions around the resident's medical appointments, resulting in missed therapy without documented rescheduling attempts.
A resident with multiple medical conditions and intact cognitive function reported seeing cockroaches in her bathroom on several occasions, but staff failed to document or investigate her complaints according to facility grievance policy. Interviews with staff confirmed that the grievance process was not initiated, and the concern was not recorded in the grievance log.
A resident with multiple medical conditions and intact cognitive function was discharged without a care plan for discharge, a completed Discharge Transition Plan, or proper delivery of the Notice of Transfer or Discharge. The resident was asked to sign a blank form, did not receive the completed document, and later discovered a form had been signed by staff without her knowledge or consent. Facility policy requiring timely and accurate discharge documentation and notification was not followed.
A resident with multiple fractures and a right wrist splint was admitted without a care plan addressing discharge planning or the management of the wrist splint. Despite being cognitively intact and able to communicate, the care plan only addressed fall risk and recent surgeries, omitting required interventions for discharge and splint care as outlined in facility policy. Staff confirmed these omissions during interviews and record reviews.
Facility staff failed to maintain accurate and complete medical records for a resident by allowing staff to sign a Notice of Transfer or Discharge form in place of the resident without proper notation or consent, and by documenting conflicting information regarding the resident's fall history. The DON confirmed discrepancies in signatures and documentation, and facility policies require clear, accurate, and complete records.
Two residents did not receive their prescribed calcium carbonate tablets on multiple occasions because the medication was not available in the medication cart. Despite facility policy requiring medications to be administered as ordered and documented, there was no evidence that the physician was notified or that an order to hold the medication was obtained, resulting in missed doses for both residents.
A resident with multiple medical conditions and moderate cognitive impairment experienced episodes of blood in the stool, leading to orders for STAT laboratory tests. After the resident refused a CBC blood draw, staff did not fully document the refusal, failed to follow facility policy for refusals, and did not update or create a care plan to address the situation.
A resident with a scheduled dialysis regimen was transported to the wrong dialysis center, resulting in a delayed and shortened dialysis session. Licensed nurses did not communicate the transport error, the reduced treatment time, or notify the MD, and key staff were unaware of the incident. Facility policies on patient identification and communication with the dialysis center were not followed.
Nursing staff failed to follow facility policy by leaving insulin syringes and medications unattended in a resident's room. On more than one occasion, insulin syringes and solutions were placed on the resident's bed and wheelchair and left without supervision, resulting in an accidental needle stick to a CNA. The resident involved had diabetes, chronic kidney disease, and major depressive disorder, and was assessed as cognitively intact.
The facility served meals to most residents in plastic containers with plastic utensils, resulting in cold and unappetizing food. Multiple residents with chronic conditions expressed frustration and reported that their complaints were not addressed by dietary staff or administration. Staff acknowledged that the use of disposable containers, due to a broken elevator, negatively affected food temperature and presentation, contrary to facility policy on resident dignity.
Due to a prolonged elevator outage, staff delivered meals using stairs and served food in disposable plastic containers, resulting in meals that were cold and unappetizing. Multiple residents, including those with hypertension and diabetes, reported dissatisfaction with the temperature and presentation of their food. Staff confirmed that the use of plastic containers did not retain heat, and the Dietary Supervisor noted this was not standard practice except in emergencies.
Surveyors observed several infection control breaches, including a CNA storing a personal cup in a clean linen cart and drinking in hallways, staff returning linen from a resident's room to a clean linen cart, failure to use gowns during care for a resident on Enhanced Barrier Precautions, improper PPE use in a contact isolation room, and undated respiratory equipment found on the floor. These actions were inconsistent with facility policies and infection prevention standards.
A resident with a physician's order for a renal diet without onions was served a meal containing onions, despite clear documentation of this preference on the meal ticket. Both the IPN and DON confirmed the error and acknowledged the importance of following dietary orders to meet the resident's nutritional needs, as required by facility policy.
A CNA in an LTC facility administered nystatin powder to a resident, following instructions from an LVN, despite not being trained or licensed to do so. The resident, who had multiple diagnoses and required assistance, was prescribed the medication for a fungal rash. Facility staff confirmed that medication administration is outside the CNA's scope of practice, and policies require licensed personnel to administer medications.
A CNA in an LTC facility administered nystatin powder to a resident without being licensed or trained to do so, following instructions from an LVN. The resident, who had conditions like osteomyelitis and peripheral vascular disease, required moderate assistance. Interviews with facility staff confirmed that medication administration is outside a CNA's scope of practice, and facility policies mandate that only licensed personnel administer medications.
A resident's medical records contained inaccurate documentation regarding the time of physician notification. The facility's system defaulted to 12 a.m. if staff did not manually enter the time, leading to discrepancies. The DON confirmed the inaccuracy, highlighting a failure to adhere to the facility's policy on timely and accurate documentation.
A facility failed to maintain an effective infection control program when a CNA did not follow Enhanced Barrier Precautions (EBP) for a resident with multi-drug-resistant organisms (MDROs). The CNA did not wear a gown while providing care and neglected hand hygiene after glove removal, contrary to facility policies. The resident had a history of gallstones with acute cholecystitis and required EBP due to MDROs.
The facility failed to obtain necessary physician's orders, informed consent, and restraint assessments for placing beds against walls for six residents, which restricted their freedom of movement and posed safety risks. Staff interviews confirmed the need for proper documentation and assessment, which was not followed.
The facility's nursing staff failed to rotate injection sites for insulin and heparin for four residents, leading to potential risks of lipodystrophy and bruising. Despite facility policies and guidelines emphasizing the importance of site rotation, records showed repeated use of the same sites. Interviews with staff confirmed the oversight and acknowledged the associated risks.
The facility failed to maintain a safe environment for residents, with deficiencies including improper medication storage at a resident's bedside, obstructed fall mats, a wet floor hazard, and unsecured smoking materials. These issues were confirmed by staff and violated facility policies, posing risks of injury and adverse effects.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to maintain resident dignity and privacy during ADL care for two residents. One resident was admitted with dysphagia, DM, and ESRD and was documented as having capacity to consent; during morning care, a CNA left the privacy curtain partially open while going between the bedside and bathroom, leaving the resident’s undressed body exposed and visible from the hallway. Another resident was admitted with cellulitis of both lower limbs, acute thrombosis and embolism of the BLE, and HTN, and was documented as having capacity to understand and make decisions; during morning care, a CNA left the privacy curtain open about two feet while providing care, and stated the curtain was not long enough to completely close the area. The facility also failed to provide mealtime assistance in a manner that maintained dignity for two residents who required extensive help with ADLs and eating. One resident had hemiplegia, hemiparesis following CVA, PVD, and generalized muscle weakness, and did not have capacity to understand and make decisions; another resident had paraplegia, schizophrenia, and generalized muscle weakness, and had intact cognition and capacity to understand and make decisions. During lunch, CNAs were observed assisting both residents while standing over them rather than sitting at eye level. The CNAs stated staff should be sitting at eye level while assisting residents with eating to respect dignity, and one CNA stated a chair was not obtained while the other stated no chairs were available and a supervisor was not notified. The facility further failed to cover urinary catheter drainage bags with dignity bags for two residents. One resident with DM, neuromuscular dysfunction of the bladder, and HTN, who required substantial/maximal assistance with toileting hygiene and showering, was observed with an indwelling catheter bag not covered by a dignity bag. Another resident with hydronephrosis, neuromuscular dysfunction of the bladder, and schizoaffective disorder, who was dependent for all ADLs, was also observed with no dignity bag covering the urinary catheter drainage bag. Staff stated that catheter bags should be covered to provide dignity and privacy and that uncovered bags could be visible and potentially make residents feel embarrassed and uncomfortable.
Call lights not within reach for multiple residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for five sampled residents: Resident 45, Resident 15, Resident 103, Resident 102, and Resident 96. The report states that each of these residents had diagnoses and assessments showing varying levels of cognitive impairment, fall risk, and need for assistance with activities of daily living. The residents’ records included care plans or fall risk evaluations identifying the need for call lights to be within reach so they could request assistance. During observations, Resident 45 was seen sleeping in bed with no call light within reach, and the call light was found on the floor behind the bedside nightstand. Resident 15’s call light was observed stuck under the mattress on the left side of the bed. Resident 103’s call light was also observed under the mattress on the left side of the bed. Resident 102’s call light was placed on the top right part of the bed next to the pillow, and the resident was observed attempting to reach it but had limited range of motion to the right arm. Resident 96’s call light was observed dangling at the left side of the bed and touching the floor. Staff interviews confirmed that the call lights were not accessible to the residents at the time of observation. The CNA, LVNs, RN, and DON stated that call lights should be within reach at all times so residents can call for help or in an emergency. The DON also stated that all staff were responsible for ensuring call lights were within residents’ reach and stated that staff did not follow the facility policy titled Call Lights: Accessibility and Timely Response. The policy stated that staff will ensure the call light is within reach of the resident and that the call system will be accessible while the resident is in bed or other sleeping accommodations.
Improper restraint use and missing assessment/order documentation
Penalty
Summary
The facility failed to ensure residents were free from the use of physical restraints unless needed for medical treatment. For one resident, the bed was placed against the wall and the most recent restraint-related assessment had been completed months earlier, despite the care plan calling for quarterly review of the resident’s comfort and safety with the bed position. During observation, the resident’s bed was still against the wall with bilateral half side rails in place, and staff stated the restraint use should have been reassessed quarterly but was not. For another resident, the bed was positioned against the wall without a physician’s order. The resident had diagnoses including cardiac arrest, gastrostomy, acute renal failure, history of falling, dysphagia, muscle weakness, and anxiety disorder, and the H&P indicated the resident did not have capacity to understand and make decisions. The care plan addressed the resident’s preference for the bed against the wall and included monitoring for skin changes and explaining risks, but staff acknowledged that a physician order had not been obtained before the bed was placed against the wall. For a third resident, wedge pillows were observed tucked under the fitted sheet on both sides of the bed. Staff stated the pillows were used for safety, positioning, and to keep the resident upright, and that the resident could not remove them because of weakness in both arms. Review of the record with RN staff confirmed there was no physician’s order for the wedge pillows under the fitted sheet, and staff stated the pillows should have been placed on top of the fitted sheet because placing them underneath restricted the resident’s movement. The resident had diagnoses including paraplegia, schizophrenia, and generalized muscle weakness, and the record showed intact cognition and that the resident usually could understand and make needs known.
Incomplete Care Plan for Indwelling Urinary Catheter Management
Penalty
Summary
The facility failed to update the comprehensive care plan for one resident with an indwelling urinary catheter to include key interventions related to catheter management. The resident was admitted with diagnoses including peripheral vascular disease, obstructive and reflex uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident’s records showed he was alert, oriented, cognitively intact, and required assistance with toileting hygiene, bathing, dressing, and mobility. Physician orders directed that he have a Foley catheter with bedside straight drainage and that the catheter be changed every 30 days while maintaining a closed drainage system. During observation and interview, the resident stated that his indwelling urinary catheter had come out about a week and a half earlier and was replaced the same day. He also stated that his urinary drainage bag had been replaced two weeks earlier and that he had not had a catheter securement device for about a month because of pain related to hair being pulled when it was removed. RN 1 confirmed that the catheter tubing did not have a date showing when it was placed, the drainage bag did not have a date showing when it was last changed, and the resident did not have a securement device in place. RN 1 also stated the resident’s catheter size was 18 Fr/10 cc balloon. Review of the resident’s nursing assessments, progress notes, and care plan showed a care plan titled impaired urinary elimination with a goal that the resident would be free from CAUTI, but it did not include interventions such as following the physician order for catheter size, replacing or changing the Foley as needed due to dislodgement, notifying the doctor and obtaining an order to reinsert if needed, changing the catheter per protocol or order, or placing a urinary catheter securement device. RN 1 stated there was no note notifying the doctor when the Foley catheter was dislodged. The DON stated the purpose of the care plan is to develop a plan of care for the resident and identified expected interventions for residents with indwelling catheters, including monitoring urine, notification of changes, catheter size, signs of infection, physician orders for leaking or removed catheters, and securement device care planning.
Improperly Placed Floor Mats and Missing Ordered Safety Devices
Penalty
Summary
The facility failed to keep the resident environment free of accident hazards for four sampled residents by not ensuring floor mats were properly placed and by not ensuring bilateral padded siderails were in place as ordered. The report states that the facility’s policy required the resident environment to remain as free of accident hazards as possible and that residents receive adequate supervision and assistive devices to prevent accidents. The manufacturer’s instructions for the floor mat also stated that the mat should be placed flat on the floor directly next to the bed and should not go under the bed, and that objects should not be placed on the product. For Resident 13, the resident had diagnoses including abnormalities of gait and mobility, disorders of bone density and structure of the right shoulder, and lack of coordination. The resident was assessed as having intact cognition and partial to set-up assistance with mobility and ADLs, and was identified as at risk for falls. During observation, the resident’s floor mat was found with the bed wheel on top of it and the mat halfway under the bed. Staff stated the mat was not placed properly and that if the resident fell, only part of the body would land on the mattress. RN 1 stated the floor mat should be checked every shift and that there was no physician order or care plan found for its use. For Resident 138, the resident had diagnoses including diabetic polyneuropathy, chronic kidney disease stage four, and hypertension, and was identified as at risk for falls. The resident’s OSR showed an order for bilateral floor mats, and the care plan addressed fall risk related to gait and balance problems. During observation, the resident’s bedside table was placed on top of the floor mat. CNA 12 stated the bedside table should not be on the mat because the resident could be injured if a fall occurred. RN 1 stated there should be no objects on top of the floor mat because it prevents the mat from serving its protective purpose. For Resident 109, the resident had legal blindness, hypertension, and a history of falls, with intact cognition and maximal assistance needed for mobility and ADLs. The care plan identified fall risk related to weakness and blindness and included keeping the room clutter-free with consistent furniture arrangement. During observation, the bedside table was on top of the floor mat. CNA 1 stated the table should not be on the mat because the resident could be injured and the table could tip over. RN 1 stated there should be no objects on top of the floor mat so it can serve its purpose. For Resident 106, the resident had paraplegia, schizophrenia, generalized muscle weakness, and a history of seizure disorder. The OSR included seizure precautions every shift, a floor mat to the right side of the bed as a landing pad, and monitoring of padded side rails for seizure precautions. The care plan also included floor mats and padded siderails as interventions. During observation and follow-up interview, CNA 3 stated the resident only had wedge pillows and was not aware of other safety precautions; the resident did not have the floor mat on the right side of the bed or padded side rails in place. RN 1 and the DON both stated that the ordered interventions should have been in place and monitored every shift as part of the resident’s safety measures.
Catheter care and urinal labeling deficiencies
Penalty
Summary
The facility failed to provide appropriate catheter care and urinary infection prevention measures for seven sampled residents with urinary catheters or urinary incontinence-related needs. For Resident 91, the physician order called for a 16 Fr Foley catheter with routine changes every 30 days and a closed drainage system, but the resident was observed with an 18 Fr catheter. The catheter tubing and drainage bag were not dated, and the resident did not have a catheter securement device in place. Resident 91 stated the securement device had been absent for about a month, and RN 1 confirmed the catheter size did not match the order, the catheter and bag were not dated, and there was no documentation showing when the catheter had been replaced after it came out. For Resident 135, an unlabeled urinal bottle was observed at the bedside, and staff stated it should have been labeled with the resident’s name and the date it was provided. For Residents 137 and 51, urinal bottles were also observed without labels. Staff interviews indicated urinals were changed weekly and should be labeled to identify the resident and the date provided, but the observed urinals did not have that information. The DON stated the lack of labeling could allow switching between residents and was not consistent with the facility’s bedpan and urinal disinfection practice. For Resident 123, the indwelling catheter drainage tubing was observed coiled in a loop. CNA staff stated catheter tubing should be straight, above the floor, and below bladder level, and that coiling could cause urine backflow. For Residents 3 and 61, record review showed physician orders for routine urinary catheter changes every 30 days, but the TARs did not document catheter changes consistent with those orders. The DON stated prolonged catheter use beyond recommended timeframes could increase the risk for UTI, catheter blockage, and discomfort. The facility policy stated indwelling catheters must be used in accordance with physician orders and that residents who are incontinent of bowel or bladder will receive appropriate treatment to prevent infections and restore continence to the extent possible.
Bed rail use lacked matching orders, consent, assessments, and care plans
Penalty
Summary
The facility failed to ensure that bed rails were properly ordered, consented to, assessed, and care planned before use for three sampled residents. The report states that for each resident, the bed rail type observed in use did not match the documentation in the chart, and in some cases there was no physician order for the device actually being used. Surveyors observed bilateral 1/2 bed rails or grab bars in use in residents’ rooms while the records reflected different rail types or incomplete documentation. For one resident, the chart contained no current order for bed rails after readmission, the consent on file was dated months earlier, and the care plan addressed bilateral 1/4 side rails rather than the bilateral 1/2 rails observed in use. The resident had diagnoses including dementia, epilepsy, and anxiety disorder, and the H&P stated the resident did not have capacity to understand and make decisions. Staff confirmed during interview that the resident was using the bed rail for mobility and that the chart lacked the needed order and updated consent for the rail actually in use. For a second resident, the record did not contain an order for bilateral grab bars, the informed consent was for 1/4 bilateral upper side rails, and the bed rail assessment was also completed for 1/4 rails rather than grab bars. Surveyors observed bilateral upper grab bars in the room, and staff stated the resident used them for mobility. The resident’s record showed diagnoses including hemiplegia, hemiparesis, dementia, and muscle weakness, and the H&P stated the resident did not have capacity to understand and make decisions. For the third resident, the chart contained two active orders, one for bilateral 1/2 side rails and one for bilateral 1/4 side rails, but staff had not clarified which order applied. The consent form did not specify what restraint was consented for, the bed safety evaluation stated there were no bed rails to be used, and the care plan addressed 1/4 side rails even though bilateral 1/2 rails were observed in use. Staff also stated the first-quarter bed rail assessment had not been completed. The resident’s record included diagnoses of gait and mobility abnormalities, weakness, and bone disorders, and the resident was observed using the 1/2 rails for mobility and repositioning.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure two sampled residents were free from significant medication errors related to insulin administration. For Resident 8, who had type 2 diabetes mellitus, intact cognition, and the capacity to understand and make decisions, the record showed an order for insulin glargine 19 units subcutaneously at bedtime with instructions to hold if blood glucose was less than 100 mg/dl. The Location of Administration Report showed repeated insulin injections in the same abdominal quadrants during January 2026, including multiple administrations in the left upper quadrant, right lower quadrant, right upper quadrant, and left lower quadrant without rotation between sites as documented. During a concurrent interview and record review, RN 1 stated there were multiple instances in January 2026 when Resident 8's insulin administration sites were not rotated. RN 1 stated insulin is a significant medication and that sites should be rotated to prevent skin lumps that can affect absorption, and stated that not rotating insulin sites is a medication error. The DON also stated that Resident 8's insulin sites should have been rotated to prevent lipodystrophy and that administering insulin on sites with lipodystrophy can cause malabsorption and hypo/hyperglycemia. The DON stated the licensed staff did not follow the facility's policy and procedure titled Timely Administration of Insulin or the facility-provided highlights of prescribing information for Lantus. For Resident 2, who had diagnoses including DM 2, difficulty walking, and generalized muscle weakness, the record indicated intact cognition and the ability to understand and make needs known, and that the resident received insulin. The DON stated that Resident 2's insulin lispro and Lantus administration sites were not rotated for March 2026. The DON stated insulin should be administered on clean sites and rotated to prevent lipodystrophy, and that failure to rotate sites can result in improper absorption and ineffective insulin action, which could lead to hypo or hyperglycemia. The facility's policies on Timely Administration of Insulin and Medication Errors, along with the manufacturer information for Lantus and insulin lispro, stated that injection sites should be rotated to reduce the risk of lipodystrophy.
Unlabeled and Undated Food in Kitchen and Resident Refrigerators
Penalty
Summary
The facility failed to label and date fresh foods held in the kitchen walk-in refrigerator, failed to discard leftover food held beyond seven days, and failed to record open dates on personal food items held in the resident refrigerator. During an observation on 4/6/2026 at 8:05 a.m., the walk-in refrigerator contained two 22-quart storage containers of mandarin oranges, two dome lids each covering a plate of lettuce, tomato, deli meat, and boiled eggs, and an uncovered plastic container of whole raw brussels sprouts, all with no label identifying the contents, received date, or preparation date. The Dietary Supervisor stated that unlabeled foods may increase the risk of food spoilage, cross-contamination, and resident illness, especially lettuce. The facility policy titled Food Safety and Food Storage stated that refrigerated food should be labeled, dated, monitored, and kept covered or in tight containers. The walk-in refrigerator also contained a metal pan and lid labeled Mix Fruit dated 3/30/2026, and the contents were observed as fruit cocktail. On 4/7/2026, the same pan remained in the refrigerator and was relabeled 4/7/26. The Dietary Supervisor stated leftovers are usually consumed within 4-6 days, but counted the open days incorrectly and acknowledged the fruit cocktail was at the ninth day and should be discarded. In the resident refrigerator across from Nurse Station 2, six bags of food containers, a plastic container with half of a tuna salad sandwich, and a plastic container with a half-eaten frosted cake had no labeled receive dates. The freezer contained five frozen pasta dinners, an opened box of individually wrapped ice cream bars, a half-eaten quart of ice cream, and a pint of ice cream with no resident name, room number, or receive/open date. The Infection Preventionist stated there was no clear policy guidance known for monitoring food items in the resident refrigerator and could not confirm ownership of a resealable plastic envelope with chocolates that had no resident name or room number.
Infection Prevention Program Failed to Maintain Clean Linen and Updated COVID-19 Vaccination Policy
Penalty
Summary
The facility failed to maintain clean linen carts in good condition when three sampled linen carts, numbers 10, 11, and 12, were observed with torn, ripped, and holed covers. During observations in the Station 1 hallway, linen cart #12 had rips, tears, and holes exposing gowns, linens, sheets, and blankets; linen cart #10 had tears, holes, and taped areas; and linen cart #11 had tears and holes. CNAs stated the carts belonged to them, that they had received them in that condition from laundry, and that they had not reported the damage. The Laundry Staff stated some linen carts were not in good condition and some covers were torn and ripped, and the Environmental Director stated the damaged covers were not acceptable to go out to the stations. The facility also failed to keep clean linens free of contamination during processing. In the laundry area, the Laundry Staff was observed folding bedsheets and blankets while holding them up in the air, and two bedsheet corners touched the floor. The Laundry Staff stated the sheets became contaminated when they touched the floor and could cause infection spread to residents. The Environmental Director stated contaminated linens that touched dirty surfaces, along with torn and ripped linen cart covers, increase the risk for infection spread among residents. The Director of Nursing stated clean linen should be folded and processed on designated clean folding surfaces and that contaminated linens could expose residents to infections and other health problems. The facility’s Employee COVID-19 Vaccinations policy was not updated to match current practice. During record review and interview, the Infection Preventionist stated employees were no longer mandated to receive COVID-19 vaccinations, while the written policy still stated that staff, except those with exemptions or temporary delays, are to be fully vaccinated or up to date. The Director of Nursing confirmed the facility’s current practice did not require employees to receive COVID-19 vaccination and stated the written policy had not been updated to reflect current practice.
Failure to Communicate Resident Visitation Restriction Request
Penalty
Summary
The facility failed to ensure visitation restrictions were addressed for one resident when it was not aware of the resident representative’s request that the resident have no visitors without the representative’s presence. Resident 41 was admitted with diagnoses including ESRD, unspecified dementia, hyperlipidemia, anemia, pneumonia, and nicotine dependence. The resident’s H&P stated that the resident lacked capacity to make and understand decisions and identified a designated family representative. The resident’s MDS indicated the resident had adequate hearing, clear speech and vision, and required extensive assistance with bed mobility, transferring, toileting, and personal hygiene, with partial to moderate assistance with eating. A review of the resident representative’s email showed a request that Resident 41 not have any visitors without the representative present and that all CNAs and charge nurses be alerted. The BOM stated she immediately forwarded the email to the SSD, but the DON stated she had not seen the email and did not know of any residents with visiting restrictions. The SSD stated he verbally reported the request to the department head but could not elaborate further, and multiple staff members stated they were unaware of any visiting restrictions for the resident. The SSD later stated that visiting restriction requests needed to be communicated to the front desk and staff, and the DON stated the request should have been communicated to all staff.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents had reasonable access to mail on Saturdays for three sampled residents who were able to understand and make decisions. Resident 17 was admitted with diagnoses including fusion of spine, cellulitis, muscle weakness, asthma, DM, and major depressive disorder. Resident 88 was admitted with diagnoses including Bell's palsy, major depressive disorder, muscle weakness, hypertension, and dysphagia. Resident 130 was admitted with diagnoses including cerebral infarction, peripheral vascular disease, facial weakness, DM, anxiety disorder, and hyperlipidemia. Their H&Ps documented that each resident had the capacity to understand others and make decisions. During interview, Residents 17, 88, and 130 stated they received mail on weekdays but not on Saturdays and did not know they could receive mail on Saturdays. The BOM stated she worked Monday through Friday, collected mail for monetary items, and forwarded the rest to the AD for distribution, but mail delivered on Saturdays was placed in the mailbox outside the facility or handed to the receptionist and distributed on Mondays. The AD stated he distributed mail Monday through Friday and that on Saturdays the receptionist received the mail because the business office was closed. The receptionist stated Saturday mail was held until Monday to give to the BOM, and the DON stated residents did not get mail on Saturdays because the business office was closed. The facility policy stated residents have the right to send and receive mail and to receive letters, packages, and other materials delivered to the facility through a means other than a postal service.
Incomplete Advance Directive Acknowledgement Documentation
Penalty
Summary
The facility failed to inform and provide written information to adult residents regarding the right to accept or refuse medical and surgical treatment and, at the resident’s option, formulate an advance directive. The deficiency involved two sampled residents, both of whom had documentation showing they were cognitively able to make decisions and had capacity to consent, yet their Advanced Healthcare Directive (AHCD) Acknowledgement Forms were not completed to show whether they had an advance directive, did not have one, or were offered assistance to complete one. Resident 12 was admitted with diagnoses including encounter for orthopedic aftercare following surgical amputation, osteomyelitis, and Type 2 diabetes mellitus without complications. The H&P indicated the resident was alert, oriented x4, and had capacity to consent, and the MDS showed the resident could make self-understood and understand others with intact cognition. Although the AHCD Acknowledgement Form stated the resident received information about the right to make an Advanced Healthcare Directive, the section indicating whether the resident had an advance directive, did not have one, or was offered assistance was left blank. During interviews, RN 1, the SSD, and the DON all stated the form was not completed correctly and did not document whether the resident had an advance directive or whether assistance was offered. Resident 71 was admitted with diagnoses including chronic respiratory failure, major depressive disorder, and anxiety disorder. The H&P indicated the resident had capacity to consent, and the MDS showed the resident could make self-understood and understand others with intact cognition. The AHCD Acknowledgment Form stated the resident received information about the right to make an Advanced Healthcare Directive, but the sections indicating whether the resident had an advance directive, did not have one, or was offered assistance were not filled out. The care plan also included an intervention to offer the opportunity to complete an advance directive. The SSD and DON stated the form was incomplete and that the missing documentation prevented the resident’s choice regarding an advance directive from being fully honored.
Broken Closet Drawer Prevented Homelike Storage for Resident
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for Resident 54 by not maintaining functional closet drawers. Resident 54 was admitted with chronic kidney disease, DM, and HTN, and the H&P documented a BIMS score of 15, indicating intact cognition. The MDS showed the resident was independent with eating, oral hygiene, personal hygiene, and upper body dressing, and required setup or clean-up assistance with showering and footwear. During observation in the resident's room, some of Resident 54's personal belongings were seen on the bed, and the resident stated the closet drawer provided had been broken for two months. The drawer was observed to have a broken bottom. During a later observation, the MA was seen addressing the broken drawer and stated that broken drawers should be addressed promptly to ensure residents maintain a homelike environment, dignity, and the ability to safely store and access personal belongings. The DON stated that when broken furniture is identified, staff need to place a work order and address the findings to maintenance immediately, and that nonfunctioning furniture can negatively affect a resident's mood and psychosocial wellbeing, potentially leading to frustration, decreased independence, and reduced quality of life.
PASRR Screening Not Updated for Resident With Schizophrenia
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for one sampled resident. The resident was admitted with diagnoses including paraplegia, schizophrenia, and generalized muscle weakness. The resident’s H&P later documented that the resident had the capacity to understand and make decisions and also listed schizophrenia, and the MDS indicated intact cognition, that the resident was usually able to understand and make needs known, and that the resident required varying levels of assistance with ADLs. The resident’s PASRR Level I Screening, dated 3/11/2023, indicated a serious diagnosed mental disorder and that a Level II Screening was required. The PASRR Level II Screening, dated 3/17/2023, stated the Level II could not be completed because the resident did not have SMI, that the case was closed, and that a new Level I Screening needed to be submitted to reopen the case. The facility did not submit a new Level I Screening despite the discrepancy between the prior PASRR findings and the resident’s admission diagnosis and records. During interviews, the MDS Coordinator stated the Admissions Director was responsible for ensuring residents had PASRR screening prior to admission and for ensuring accuracy, but was unsure who was responsible for submitting a new Level I Screening when there was a discrepancy. The Social Services Director stated he reviewed PASRR with the Admissions Director and during stand-up meetings, but was not sure who was directly responsible for ensuring PASRR matched the admission diagnosis and H&P. The DON stated the Admissions Director obtains and submits a new Level I Screening when there is a discrepancy and that a new Level I Screening should have been submitted because the resident’s admission records showed schizophrenia.
Failure to Develop Comprehensive Care Plan for Schizophrenia
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 106 that addressed schizophrenia. Resident 106 was admitted on 3/18/2024 with diagnoses including paraplegia, schizophrenia, and generalized muscle weakness. The H&P dated 3/5/2026 indicated the resident had the capacity to understand and make decisions and had schizophrenia. The MDS indicated the resident had intact cognition, was usually able to understand and make needs known, required supervision or touching assistance with eating and oral hygiene, and substantial or maximal assistance with all other ADLs, and also identified schizophrenia. A review of the resident’s care plans showed no care plan developed and implemented for schizophrenia. During interview and record review, RN 1 stated the resident’s records showed a diagnosis of schizophrenia and that no care plan had been developed and implemented for it. RN 1 stated comprehensive care plans are developed within 14 days of admission and are important so staff are aware of the resident’s plan of care. The DON stated baseline care plans are developed within 48 hours of admission and comprehensive care plans are developed seven days after completion of the admission MDS assessment or 21 days after admission, and that Resident 106’s care plan should have been developed and implemented timely so staff would be aware of the current plan of care.
Failure to Provide Communication Tools for a Resident with Hearing Impairment
Penalty
Summary
The facility failed to ensure effective communication for one resident with hearing impairment when no communication board or other alternative communication tools were provided in the resident’s room. Resident 61 was admitted and later readmitted with diagnoses including Huntington disease, right-sided hemiplegia, right-sided hemiparesis, and obstructive uropathy. The resident’s H&P stated that he had the capacity to understand and make decisions, and the MDS identified moderate hearing difficulty. During an interview in the resident’s room, he stated that he was unable to hear any questions asked, and attempts to communicate using slower speech, simple words, and increased volume were unsuccessful. No communication board or other alternative communication tools were observed in the room. During a concurrent interview and record review, the LVN stated that the resident had hearing impairment and that she communicated by talking slowly and with a loud voice. She also stated that residents with hearing impairment are referred to social services for an ENT consult, and she confirmed that no communication board or other communication tools were present in the room. The SSD stated that communication boards and visual tools are utilized to help residents understand information and express needs, and the DON stated that the facility was responsible for ensuring communication tools such as a communication board, hearing amplifiers, or other interventions identified in the care plan were provided and used. The facility policy on Effective Communication stated that staff should accommodate residents with communication difficulties and that adaptive techniques include communication boards or writing materials.
Failure to Provide Routine Nail Care and Grooming
Penalty
Summary
The facility failed to provide necessary ADL care, specifically grooming and nail care, for Resident 43. Resident 43 was admitted and later readmitted with diagnoses including DM, peripheral vascular disease, atrial fibrillation, and right foot amputation. The H&P dated 7/9/2025 indicated the resident had capacity to understand and make decisions. The MDS dated 10/1/2025 showed the resident required substantial/maximal assistance with toileting hygiene, upper and lower body dressing, and putting on/taking off footwear. The care plan revised on 1/2/2026 identified the resident as at risk for decreased ability to perform ADLs including bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting, and included an intervention for staff to provide assistance of one person with personal hygiene, including grooming. During observation on 4/6/2026 at 10:20 a.m., Resident 43 was seen with long fingernails on both hands with visible dark debris underneath the nails. During a concurrent interview, CNA 2 stated CNAs were responsible to keep residents clean and groomed and acknowledged that Resident 43's fingernails were too long and had black dirt residue under them. RN 1 stated that all licensed personnel were responsible for ensuring residents' grooming and hygiene needs were met and that nail care should be provided during routine care, including showers and morning hygiene. The DON stated CNAs are responsible to provide routine ADL care, including nail care. The facility's Nail Care policy stated that routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis, with routine nail care including trimming and filing provided on a regular schedule and between scheduled occasions as needed.
Low Air Loss Mattress Not Set According to Resident Weight
Penalty
Summary
The facility failed to ensure Resident 85 received pressure ulcer care consistent with professional standards when the resident’s low air loss mattress was not set according to weight. Resident 85 was admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, and cerebral infarction. The history and physical indicated the resident did not have the capacity to understand and make decisions, and the MDS showed severe cognitive impairment, dependence for mobility and ADLs, frequent incontinence of urine and stool, and risk for pressure injuries. The resident’s record included an order for a low air loss mattress for wound management with instructions to monitor the setting for accuracy and functionality every shift. The resident also had an order for treatment of an abrasion to the coccyx, and the care plan identified risk for impaired skin integrity with use of a pressure-redistributing mattress. The Braden Scale dated 3/31/2026 indicated the resident was at risk for developing pressure injuries, and the resident’s weight was documented as 121 pounds. During observation on 4/6/2026, the resident’s low air loss mattress was found set at 80, the softest setting, while a sticker on the machine indicated the setting should be 180. LVN 6 stated the setting should be adjusted to 180 and that failure to set the bed according to the resident’s weight could lead to worsening of the pressure sore. RN 1 later stated the mattress should be set according to weight and that, based on the resident’s 121-pound weight, the setting should be 120, not 180. The DON also stated the mattress should be set according to weight and that the treatment nurses should check the setting every shift; the DON stated the facility’s pressure injury prevention guideline and the mattress user manual were not followed.
Unlabeled enteral water flush bag
Penalty
Summary
Staff failed to ensure proper labeling of the water flush bag used for enteral hydration for a resident with a feeding tube. Resident 136 was admitted with diagnoses including gastrostomy, type 2 DM, and chronic kidney disease, and the H&P stated the resident did not have the capacity to understand and make decisions. The resident’s OSR included an order for enteral water flush at 30 ml/hr for 20 hours via pump, and the care plan addressed dependence on enteral nutrition with monitoring for dehydration and provision of enteral flushes as ordered. During observation, the resident’s water flush bag was seen hanging on an IV pole attached to a feeding pump without the rate of infusion labeled. LVN 1 stated the water flush bag should be labeled with the rate of infusion to ensure accurate water hydration was being provided. RN 1 later reviewed the picture and the resident’s orders and stated the bag was missing the rate of infusion, which was used during shift handoff to verify the physician’s current enteral feeding and water flush orders. RN 1 and the DON both stated that failure to label the water flush bag with the rate of infusion could cause error and could potentially lead to under or overhydration. The DON stated the bag should be labeled with the resident’s name, date and time hung, formula name, rate of infusion, and the initials of the licensed nurse who hung it. The facility’s tube feeding information also stated that enteral formula containers should be labeled with patient identifiers, formula name, date and time prepared and hung, route, rate, duration, initials, expiration, dosing weight if appropriate, and ENTERAL USE ONLY.
Midline Dressing Not Dated and Not Changed on Schedule
Penalty
Summary
The facility failed to ensure safe, appropriate administration of IV fluids for one sampled resident by not ensuring the resident’s midline catheter dressing was labeled with the date of the last dressing change. Resident 28 was admitted with diagnoses including osteomyelitis, absence of right toes, and absence of the right leg above the knee. The resident’s record showed intact cognition and the ability to understand others and make needs known. Physician orders included IV tubing changes every 24 hours, IV site checks every shift, and PICC/midline transparent dressing changes every Saturday for site maintenance. During observation on 4/6/2026, Resident 28 was lying in bed with an IV line on the right upper arm dated 3/28/2026. RN 2 stated the date on the midline indicated the last dressing change and that the dressing was past the 7-day interval, which should have been changed on 4/4/2026. RN 2 and the DON both stated IV site dressings should be changed every 7 days and labeled with the date of the last change. The DON stated the dressing had not been changed timely. The facility policy titled PICC/Midline/CVAD Dressing Change stated PICC, midline, or central venous access device dressings are to be changed weekly or if soiled.
Unsafe Oxygen Tubing Handling
Penalty
Summary
Respiratory care was not provided in accordance with professional standards for two residents when oxygen tubing was found in unsafe conditions. One resident was admitted with chronic respiratory failure with hypercapnia, obstructive sleep apnea, and morbid obesity, and had intact cognition and capacity to consent. The resident had an order for oxygen by nasal cannula as needed, with instructions to titrate oxygen to keep saturation above 90%, and to change the nasal cannula, oxygen tubing, and humidifier weekly as needed or when soiled. During a concurrent observation and interview, the resident’s oxygen tubing was seen at the foot of the bed coiled to the oxygen concentrator, with most of the tubing touching the floor and disconnected from the resident. A CNA stated the tubing was touching the floor and needed to be changed due to infection issue. An RN later stated all staff were responsible for ensuring oxygen tubing was kept off the floor, that tubing on the floor should be removed and replaced immediately to prevent respiratory infections, and that the facility’s Oxygen Administration policy was not followed. The DON stated the tubing should have been placed in a clear plastic bag with the date and resident name to ensure safe use, and stated the tubing on the floor predisposed the resident to respiratory infection. A second resident, admitted with gangrene, acute systolic heart failure, and type 2 diabetes mellitus without complications, also had intact cognition and required maximal assistance to supervision with several activities of daily living. During observation, the resident’s oxygen tubing was seen touching the floor, touching the trash can, and under the bedside table. An LVN stated the tubing should not touch the floor or trash can for infection prevention and that it could get caught on the bedside table wheel and be pulled out. An RN stated it was not appropriate for oxygen tubing to touch the floor or trash can because the resident could possibly get an infection, and that tubing should not be under the table because it could cause a blockage if the wheel went over it or become tangled, preventing the resident from receiving needed oxygen. The DON stated the tubing should not touch the floor to prevent respiratory infection and that there was a risk of the tubing being pulled off or kinked by the table wheel.
Failure to Verify Resident Identity and Assess Pain Before Administering PRN Medication
Penalty
Summary
LVN 2 failed to accurately identify Resident 117 and failed to assess the resident’s pain level before administering pain medication. Resident 117 was admitted with diagnoses including alcoholic cirrhosis of the liver without ascites, heart failure, and hypothyroidism. The MDS dated 3/9/2026 indicated the resident could make self-understood and understand others, had intact cognitive function, and required supervision with bed mobility, transfers, dressing, toilet use, and personal hygiene. The OSR dated 12/27/2025 ordered acetaminophen 325 mg, two tablets by mouth every 4 hours as needed for pain level 1-6/10. During a concurrent observation, interview, and record review on 4/6/2026, Resident 117 complained of leg pain and requested medication. LVN 2 administered medication but did not verify the resident’s name and birthday and did not ask for the pain level. LVN 2 reviewed the acetaminophen order and stated the resident had earlier received hydrocodone for 8/10 pain and that only acetaminophen was available. Resident 117 stated her current pain level was 8/10. LVN 2 stated acetaminophen should not have been given because it was ordered for pain level 1-6/10 and that the doctor should have been called; LVN 2 also stated non-pharmacological measures such as repositioning the legs could have been used. RN 1 and the DON both stated the resident should have been identified, pain assessed, the OSR followed, and non-pharmacological interventions used before administering pain medication.
Inaccurate Hearing Assessment and Missing Communication Documentation
Penalty
Summary
The facility failed to ensure that one sampled resident’s hearing assessment was accurately documented to reflect the resident’s impaired hearing. Resident 61 was admitted and later readmitted with diagnoses including Huntington disease, right-sided hemiplegia, hemiparesis, and obstructive uropathy. The resident’s H&P stated he had capacity to understand and make decisions, and the MDS dated 1/22/2026 indicated moderate hearing difficulty, with the speaker needing to increase volume and speak distinctly. During an interview on 4/6/2026, Resident 61 stated he was unable to hear questions asked and continued to have difficulty hearing even when staff used slower speech, simple words, and increased volume. No communication board or other alternative communication tools were observed in the resident’s room. During a concurrent interview, LVN 1 stated Resident 61 had hearing impairment and that residents with hearing impairment are referred to social services for ENT consultation scheduling. The Order Summary Report showed a physician’s order on 2/19/2026 for an ENT consult for hearing loss. Despite these findings, weekly Nursing Assessments dated 3/9/2026, 3/16/2026, 3/23/2026, and 4/6/2026 documented adequate hearing. The care plan also contained no documentation for hearing impairment or impaired communication, and progress notes for February and March 2026 contained no documentation of follow-up for the ENT consultation. The SSD stated that residents with identified hearing impairment are referred to ENT, individualized care plans are developed to address communication needs, and communication boards and visual tools are used, but no social work assessment or progress notes had been completed or documented.
Incomplete Hospice Binder and Missed Ordered Hospice Visits
Penalty
Summary
The facility failed to ensure hospice services were provided to a resident according to the Hospice Orders/Visit Frequency List and failed to maintain complete hospice documentation in the hospice binder. Resident 5 was admitted and later readmitted with diagnoses including malignant neoplasm of the pancreas, malignant neoplasm of bone, and chronic kidney disease stage 3B. The resident’s MDS dated 12/22/2025 indicated the resident could make self-understood and understand others and had intact cognition. The resident’s OSR included orders for hospice admission under Hospice A, DNR, comfort care only, no transfers, no IV fluids, and to call Hospice A for any change in condition. The POLST dated 12/17/2025 indicated DNR/Allow Natural Death, comfort-focused treatment, and no artificial means of nutrition including feeding tubes. The resident’s VFG dated 4/8/2026 listed planned hospice visits by discipline across multiple weeks, including nurse, social worker, chaplain, and home health aide visits. Review of the Vitas Staff Assignments and Vitas Visit Description Log for 1/2026 through 4/2026 showed missing signatures and were not congruent with the VFG. Review of the Visit Notes in the hospice binder showed multiple weeks where the number of visits completed did not match the frequency listed on the VFG, including weeks with fewer nurse visits than ordered, missing social worker visits, missing chaplain visits, and a missing home health aide visit. During interviews on 4/8/2026, the SSD stated he could not find the physician’s order for the frequency of nurse, social worker, chaplain, and home health aide visits in the binder and could not reconcile how often each discipline should have visited because the order was missing. He also stated there were many missing visit notes and that he was responsible for coordinating hospice care in the facility and ensuring the hospice binder was complete. The DON stated the SSD and medical records should have ensured the hospice binder contained the physician’s order, signatures of entity visits, and visit notes so hospice care could be provided according to the physician’s order.
Failure to Document Physician Reason for Continued Antibiotics
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not ensuring that the physician documented a reason for continuing antibiotic therapy when Resident 28 did not meet the criteria for continued use. Resident 28 was admitted with diagnoses including osteomyelitis, absence of right toes, and absence of the right leg above the knee, and was documented as having intact cognition and the ability to understand and make decisions. The resident’s MDS indicated IV access and IV antibiotic use. Resident 28 had physician orders for levofloxacin for UTI, ertapenem sodium for ESBL, and vancomycin hydrochloride for diabetic infection of the left foot. Infection screening evaluation forms dated 3/2/2026 for acute dysuria and redness on the wound/skin indicated the resident had no fever, no respirations greater than 25 per minute, no low blood pressure, no pulse rate greater than 100 beats per minute, and no other symptoms noted. Antibiotic Time Out forms dated 3/6/2026 for levofloxacin, ertapenem sodium, and vancomycin hydrochloride indicated the resident remained afebrile, had no trending changes in vital signs, and had no current symptoms of infection. The Antibiotic Time Out forms also indicated that the physician was notified and aware of the resident’s clinical status and the rationale for an antibiotic time out, and the physician stated to continue the current antibiotic orders but did not document a reason for continuing therapy. During interview, the IP stated the physician verbally said the antibiotics could not be stopped abruptly, but this was not documented on the form. The DON stated the IP should have documented the physician’s reason for continuation in the antibiotic time out form, and the facility policy required antibiotic orders to specify the dose, duration, and indication for use and to review antibiotic orders for appropriateness.
Bed Controller Found in Disrepair
Penalty
Summary
The facility failed to maintain Resident 129’s bed controller in safe operating condition. Resident 129 was admitted with diagnoses including dementia, difficulty walking, and generalized muscle weakness, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident was sometimes able to understand others and make needs known, had severely impaired cognition, and required varying levels of assistance with ADLs, including substantial to total assistance for several tasks. During an observation in the resident’s room, the bed control was seen on the resident’s left side with the touch pad cover peeling off and the cord showing exposed wires covered with black plastic tape. During a concurrent observation and interview, an LVN stated the touch pad cover was peeling and the cord had exposed wires covered with black electrical tape. When tested, the bed did not begin moving up until the up-arrow button was pressed at least three times. The LVN stated she was not aware the bed control was in disrepair and said staff should notify maintenance as soon as possible when resident care equipment is found in disrepair. An RN stated that whenever staff observe resident care equipment in disrepair, maintenance should be notified as soon as possible because equipment not in safe operating condition does not provide a safe environment for the resident. The DON stated maintenance makes monthly rounds, but if broken equipment is not seen, staff are responsible for notifying maintenance to replace it. The DON also stated Resident 129’s bed control should have been replaced because it was in disrepair, with a peeling touch pad cover and exposed wires on the cord covered with electrical tape.
Nonfunctional Bathroom Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that bathroom call lights were functional in three residents’ rooms, as required by facility policy. For one resident with CHF, chronic kidney disease, muscle weakness, and lack of coordination, records showed intact cognition and a need for maximal assistance with lower body dressing, moderate assistance with toileting hygiene, and supervision with toilet transfers. During observation with a CNA in this resident’s room, pulling the bathroom call light cord did not activate the call light indicator outside the room. The CNA reported that the resident had complained the previous day that the bathroom call light was not working, and that when the CNA checked it then, the light indicator flashed but there was no audible sound; the CNA could not recall if she had reported this malfunction to other staff. A second resident, admitted with peripheral vascular disease, myalgia, and muscle spasms, had intact cognition and required supervision for toileting hygiene and lower body dressing, and was always continent of bowel. During observation in this resident’s room, when the CNA activated the bathroom call light, the call light indicator outside the room did not activate. The CNA stated that the call light indicator was not functioning and that the resident would not be able to call for assistance from the bathroom. A third resident, with diagnoses including heart failure, anxiety disorder, muscle weakness, and left hip pain, had intact cognition and required moderate assistance with toileting hygiene and toilet transfers, and was always continent of bowel and bladder. During observation with the Environmental Director in this resident’s room, pulling the bathroom call light cord did not activate the call light indicator outside the room. In an interview, the Environmental Director stated there was no documented evidence that the call light system, including bathroom switches, was assessed for functionality, and reported there was a loose connection in the system wiring that potentially caused the malfunctioning bathroom call lights. The Environmental Director and the DON both stated that all resident rooms should have functioning call light systems and that failure to have functional bathroom call lights could potentially delay care and increase fall risk. Review of the facility’s policy on call lights indicated that the call system must be accessible at each toilet and bath or shower facility and that staff will report problems with call lights or the call system to the supervisor and/or maintenance director.
Failure to Care Plan for New Dialysis Port Catheter
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables to address a resident’s left upper chest port catheter used for renal dialysis. The resident was originally admitted with diagnoses including dementia, dependence on renal dialysis, and stage four chronic kidney disease, and was later readmitted after a hospitalization during which the dialysis access was changed from an arteriovenous fistula to a left upper chest port catheter. The resident’s history and physical documented fluctuating capacity to understand and make decisions, and the Minimum Data Set showed severely impaired cognitive functioning and dependence on staff for eating, oral care, toileting hygiene, showers, personal hygiene, and dressing. During concurrent interview and record review, RN 1 confirmed that the resident’s care plan did not include any plan for care and monitoring of the left upper chest port catheter and had not been updated upon readmission to reflect the new dialysis access site. RN 1 stated that the care plan should have been updated to address the accurate dialysis access site to provide proper monitoring. The DON also stated that the care plan should have been developed upon admission to address the new renal dialysis access site and how to manage and care for it, and acknowledged that the resident’s care plan was not person-centered and complete because it lacked a plan for the dialysis access site. The facility’s policy on Comprehensive Care Plans required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs, including services to attain or maintain the resident’s highest practicable well-being.
Failure to Maintain E-Kits and Proper Medication Disposal Procedures
Penalty
Summary
Surveyors identified a failure to maintain pharmaceutical services and emergency medication kits in accordance with facility policy and pharmacy agreements. At nurse station 2, an IM emergency kit contained a vial of bacteriostatic water 30 ml in slot 20 that had expired on 11/1/2025 and remained in the kit for 75 days past expiration. RN 1, who opened the locked medication room, acknowledged she had not checked the e-kit and stated expired medications could be contaminated and lose effectiveness. Across nurse stations 1, 2, and 3, RN 1 was unable to locate any e-kit logs, and LVN 1 stated there were no e-kit logs in the facility and that he did not consistently perform visual checks on the e-kits at nurse stations 2 and 3. The facility did not provide documentation that the 15 e-kits in the facility were checked every shift as required by the DON’s stated process. The survey also found failures in the disposition and documentation of resident medications. Resident 4 was admitted with diagnoses including nontraumatic intracerebral hemorrhage, cerebral edema, and atelectasis, and expired on 7/28/2025. On 1/14/2026, RN 1 located a white paper bag containing Resident 4’s medications on the top shelf of a cabinet in the locked medication room at nurse station 2. RN 1 stated that medications for discharged residents should be disposed of and documented on the Medication Disposition Record and Pass Log, but she could not locate these logs for nurse station 2. The DON later stated that medications of discharged residents should be destroyed within 90 days of discharge, while Resident 4’s medications remained in the facility for 179 days after discharge. Record reviews of Medication Disposition Record and Pass Logs at nurse stations 1 and 3 revealed additional deficiencies in medication destruction practices. At nurse station 3, the log dated 10/13/2025 showed two medications documented as disposed of in waste management without a second licensed nurse’s signature as witness, contrary to facility policy requiring two licensed nurses to witness destruction of non-controlled medications. At nurse station 1, the log dated 10/19/2025 showed five medications documented as disposed of in a trash bin, which the DON stated was not an approved method of medication disposition, and these entries also lacked a second nurse’s witness signature. The DON confirmed that the facility failed to follow its process for proper medication disposal and that e-kits were expected to be checked every shift to ensure emergency medications were not expired and kits were intact.
Failure to Provide Post-Fall Assessment, Splint Care Orders, and Therapy Coordination
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who was admitted with multiple diagnoses, including muscle weakness, polyneuropathy, and fractures of the right lower leg and right hand. The resident, who was cognitively intact and able to communicate needs, experienced a fall in the bathroom after being startled by cockroaches. Following the fall, facility staff did not initiate a Change of Condition (COC) form, notify the physician, or complete a post-fall assessment as required by facility policy. There was no documentation of a comprehensive assessment, physician notification, or monitoring for post-fall complications, despite staff interviews confirming these actions should have occurred. Additionally, the facility did not obtain physician orders for the care of the resident's right wrist and distal forearm splint, which had been applied during a prior hospital stay. The absence of such orders meant that staff lacked guidance on proper splint management, as confirmed by both the Assistant Director of Rehabilitation and the Director of Nursing. Facility policy required that care for prosthetic and orthotic devices be consistent with professional standards and individualized care plans, but there was no evidence that these standards were met for the resident's splint. The facility also failed to coordinate and schedule occupational and physical therapy sessions around the resident's outpatient medical appointments. As a result, the resident missed therapy sessions on days when she was out of the facility for medical appointments, and there was no documentation of attempts to reschedule or provide therapy at alternative times. The lack of coordination was acknowledged by both the rehabilitation staff and the Director of Nursing, who noted that therapy staff should have communicated with the resident and made multiple attempts to ensure therapy was provided.
Failure to Investigate and Address Resident Grievance Regarding Pest Infestation
Penalty
Summary
The facility failed to promptly address and investigate grievances reported by a resident who was admitted with multiple diagnoses, including muscle weakness, polyneuropathy, and fractures. The resident, who was cognitively intact and able to communicate clearly, reported seeing cockroaches in her bathroom on several occasions shortly after admission. Despite making multiple complaints to facility staff, her concerns were not addressed, and no grievance form was initiated as required by facility policy. Interviews with staff, including a registered nurse, the Social Services Director, and the Director of Nursing, confirmed that the resident's complaints were not documented or investigated according to the facility's grievance procedures. The facility's grievance log did not show any record of the resident's concern, and staff acknowledged that the grievance process should have been initiated to ensure the resident's concerns were properly addressed. The failure to follow the established grievance policy resulted in the resident's right to voice grievances without discrimination or reprisal not being honored.
Failure to Provide Required Discharge Planning and Notification
Penalty
Summary
The facility failed to follow its own Discharge Planning Process policy for a resident by not initiating a discharge care plan upon admission, not providing a completed Discharge Transition Plan prior to discharge, and not giving the required Notice of Transfer or Discharge form to the resident before discharge. The resident was admitted with multiple diagnoses, including muscle weakness, polyneuropathy, and fractures, and was assessed as having intact cognitive function and the ability to make decisions. Despite this, the care plan did not include a discharge plan from the time of admission, and the Discharge Plan Documentation form was not completed before the resident left the facility. Interviews and record reviews revealed that the resident was approached by a nurse with a blank Notice of Transfer or Discharge form and requested to sign it. The resident declined to sign until she could review the completed form, but the nurse did not return with it. After discharge, the resident found a signed Notice of Transfer or Discharge form in her packet, but stated she did not sign it and was not given the opportunity to review or discuss its contents. The DON confirmed that the signature on the form did not match the resident's known signature and appeared to have been signed by facility staff without proper notation or explanation. Facility policy required that discharge planning begin upon admission and that residents be provided with a Discharge Transition Plan and Notice of Transfer or Discharge, including information about their rights and the reason for discharge. The DON acknowledged that these steps were not followed, and that documentation practices did not meet the facility's standards for accuracy and transparency. The failure to provide the required documentation and notification meant the resident was not properly informed of her discharge or her rights.
Failure to Develop and Implement Complete Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that included measurable objectives and timetables to meet all of a resident's needs. Specifically, upon admission, the care plan did not address discharge planning for a resident who had multiple diagnoses, including muscle weakness, polyneuropathy, unspecified fractures of the right lower leg and right hand, and was using a right wrist and distal forearm splint. The resident was cognitively intact, able to communicate needs, and required supervision for some activities of daily living, but was otherwise independent with personal hygiene and used a crutch for mobility. Record reviews and staff interviews revealed that the care plan initiated at admission focused on fall risk and recent surgical interventions but omitted both discharge planning and interventions related to the resident's right wrist splint. The Director of Nursing (DON) confirmed that discharge planning was not initiated as required by facility policy, which mandates that discharge planning begin upon admission and be incorporated into the person-centered care plan process. The DON acknowledged that this omission could result in the resident's discharge goals not being identified or met. Additionally, the care plan did not address the presence of the right wrist and distal forearm splint, despite documentation in hospital and occupational therapy records. Staff interviews confirmed that the care plan should have included interventions for the splint to guide staff in supporting the resident's healing process and preventing complications. Facility policy requires that care plans address all identified needs with measurable objectives and timeframes, but this was not followed in the resident's case.
Failure to Maintain Accurate Medical Records and Proper Discharge Documentation
Penalty
Summary
Facility staff failed to maintain accurate and complete medical records for a resident, specifically regarding the Notice of Transfer or Discharge form. The resident, who was cognitively intact and able to make decisions, reported that a registered nurse (RN) initially presented a blank discharge notice for signature, which the resident declined to sign until she could review the completed form. The RN left with the form and did not return, and the resident later discovered a signed discharge notice in her discharge packet after leaving the facility. The resident stated she did not sign the form and was not given the opportunity to review or discuss its contents prior to discharge. The Director of Nursing (DON) confirmed that the signature on the discharge notice did not match the resident's known signature and appeared to have been signed by facility staff without any notation indicating it was not the resident's signature or that verbal consent was obtained. Additionally, there were inconsistencies in the resident's fall risk documentation. The initial fall risk assessment, completed by a registered nurse upon admission, was not dated, and there was conflicting information between the fall risk assessment and the nursing documentation regarding whether the resident had experienced a fall in the months prior to admission. The DON acknowledged the discrepancy and noted that accurate and complete documentation is necessary for proper care planning, particularly for fall prevention interventions. Facility policies reviewed indicated that nursing documentation should be clear, accurate, and reflective of the care provided, and that falsification or improper correction of records is not permitted. The policies also required that documentation be complete, relevant, and signed by the person making the entry, with the date and time recorded. The failure to follow these standards resulted in incomplete and inaccurate records for the resident, including a falsified discharge notice and contradictory fall risk information.
Failure to Administer Physician-Ordered Calcium Carbonate Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure that two residents received their prescribed calcium carbonate oral tablets as ordered by their physicians. For both residents, physician orders specified daily or twice-daily administration of calcium carbonate for conditions such as osteoporosis and supplementation. However, medication administration records and interviews revealed that the medication was not available in the medication cart on multiple occasions, resulting in missed doses over the course of a week for each resident. For the first resident, who had diagnoses including chronic kidney disease, type 2 diabetes mellitus, and muscle weakness, the calcium carbonate was not administered on several specified dates. Although the attending physician was reportedly notified and ordered the medication to be held until available, there was no documented evidence of this notification or order in the resident's records. The facility's own policy required medications to be administered as ordered and for any administration to be documented immediately on the medication administration record (MAR), but this was not followed. Similarly, the second resident, with diagnoses including acute kidney failure, type 2 diabetes mellitus, and gastro-esophageal reflux disease, did not receive the ordered calcium carbonate on multiple dates due to unavailability. Again, there was no documented evidence that the physician was notified or that an order to hold the medication was obtained. The facility's policy and procedure for medication administration, which mandates adherence to physician orders and proper documentation, was not followed in these instances.
Failure to Update Care Plan After Resident Refusal of Blood Draw
Penalty
Summary
A deficiency occurred when the facility failed to develop and update a comprehensive, person-centered care plan for a resident who refused a blood draw for a complete blood count (CBC) test. The resident, admitted with diagnoses including metabolic encephalopathy, altered mental status, type 2 diabetes mellitus, and essential hypertension, was noted to be moderately impaired in thought process and required substantial assistance with activities of daily living. The resident experienced episodes of blood in the stool, prompting orders for STAT laboratory tests, including a CBC and occult blood test. Despite the physician and nurse practitioner being notified and orders being placed, the resident refused the CBC blood draw. Multiple staff members, including RNs and laboratory staff, attempted to encourage the resident to comply, but the refusal persisted. Documentation of the refusal, the attempts to obtain the sample, and communication with the medical team were either incomplete or missing. Staff interviews revealed that required steps per facility policy—such as offering the procedure three times, explaining risks and benefits, notifying the physician, and documenting all actions—were not fully carried out or recorded in the resident's medical record. Further review confirmed that no care plan was developed to address the resident's refusal of the CBC blood draw. Both nursing staff and the Director of Nursing acknowledged that a care plan should have been created to identify interventions for the refusal and to monitor the resident's condition. The facility's policy required a baseline care plan for each resident, but this was not implemented in this case.
Failure to Ensure Proper Communication and Transport for Dialysis Care
Penalty
Summary
Licensed nurses failed to follow professional standards of practice for a resident requiring dialysis by not ensuring accurate communication with transport services regarding the correct dialysis center. On one occasion, the resident was transported to the wrong dialysis center, resulting in a delayed start to the dialysis treatment and a reduction in treatment time from three hours to two hours. The facility's records indicated that the resident had a scheduled dialysis regimen, and the error in transportation led to a shortened session. Additionally, there was a lack of communication among licensed nurses about the resident's late transport and decreased dialysis treatment duration. The attending physician was not notified of the shortened dialysis session. Interviews with staff confirmed that key personnel, including the Assistant Director of Nursing, were not informed about the incident or the resident's altered treatment. The facility's policies required the use of at least two patient identifiers and ongoing communication with the dialysis center, but these procedures were not followed in this case.
Unattended Insulin Syringes and Medications Left in Resident Room
Penalty
Summary
Facility staff failed to ensure that medications, specifically insulin syringes and solutions, were not left unattended in a resident's room. On multiple occasions, nursing staff placed insulin syringes and medications on the resident's bed and wheelchair and then left the room, leaving the medications unattended. This was observed both during a surveyor's visit and confirmed through staff interviews. The unattended medications included Novolog and Novolin R insulin solutions, which were prepared for a resident with type 2 diabetes mellitus, chronic kidney disease, and major depressive disorder. The resident was assessed as having intact cognitive skills and the capacity to make decisions. The facility's own policies required that medications be administered at the time they are prepared and not left unattended unless specifically authorized for bedside storage. Despite this, staff admitted to leaving insulin syringes and medications unattended, and one incident resulted in a certified nursing assistant being accidentally poked by a syringe left on the resident's wheelchair. Staff interviews confirmed awareness that medications should not be left unattended, and the facility's policies were not followed in these instances.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain or enhance residents' dignity and individuality by serving meals to 151 out of 158 sampled residents in plastic containers with plastic utensils. Multiple residents reported that the food was cold, unappetizing, and difficult to eat from the plastic containers. Residents expressed frustration and dissatisfaction, stating that their concerns were not addressed by the dietary supervisor or administration. Observations confirmed that food temperatures were significantly lower when served to residents compared to the temperatures recorded at the service line, and staff acknowledged that the plastic containers did not retain heat effectively. Interviews with residents and staff revealed ongoing complaints about the quality and presentation of meals, with residents stating that the use of disposable containers was not appropriate for their home environment. The facility's use of disposable containers was attributed to a non-functioning elevator, requiring staff to pass trays via stairs. Despite this, the facility's own policy emphasized the importance of treating residents with respect and dignity and providing a homelike environment, which was not upheld in this situation.
Failure to Serve Food at Safe and Appetizing Temperatures Due to Elevator Outage
Penalty
Summary
The facility failed to prepare and serve food in a manner that conserved temperature, flavor, and appearance, resulting in residents receiving meals that were not palatable, attractive, or at a safe and appetizing temperature. Due to an inoperable elevator, staff distributed food using stairs and served meals in plastic containers, which did not retain heat effectively. Multiple residents reported that their food and beverages, such as coffee, were cold and unappetizing, and staff interviews confirmed that the use of disposable containers contributed to the food being barely warm and not presentable. The Dietary Supervisor acknowledged that the use of plastic containers was only intended for emergencies and that it negatively impacted the dining experience. The deficiency affected a large number of residents, including those on regular, therapeutic, and puree diets. Residents with medical conditions such as hypertension and diabetes expressed dissatisfaction with the food temperature and presentation. Staff interviews and record reviews revealed that the elevator repair was delayed due to payment disputes with the elevator company, resulting in prolonged use of stairs and disposable containers for meal delivery. Facility policy required food to be prepared in accordance with the FDA Food Code, but observations and interviews indicated that this standard was not met during the period in question.
Multiple Infection Control Breaches Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed breaches in infection control practices. Certified Nursing Assistant (CNA) 1 was seen drinking from a personal cup in the hallway and storing it inside a clean linen cart, despite acknowledging that this practice was not permitted due to contamination risks. CNA 1 continued to store the cup in the dirty linen cart after being observed. Additionally, CNA 2 was observed returning clean linen from a resident's bed to a clean linen cart, believing it was acceptable because the linen was in a plastic bag, but later confirmed with the Infection Preventionist that this practice was not allowed due to cross-contamination concerns. Enhanced Barrier Precautions (EBP) were not implemented as required for a resident with wound care needs. CNA 7 was observed not wearing a gown while providing care and changing bed sheets for a resident on EBP, despite being aware that a gown should be worn to prevent the spread of bacteria. Furthermore, staff failed to wear appropriate Personal Protective Equipment (PPE) when entering a contact isolation room, and gloves were worn in the hallway, contrary to facility policy and infection control standards. Additional deficiencies included the failure to date a nasal cannula and humidifier for a resident, with the nasal cannula found on the floor and both items undated. The Registered Nurse (RN) acknowledged that these items must be dated to track when they were last changed to prevent infection. Facility policies reviewed confirmed the requirements for proper linen handling, PPE use, and equipment dating, all of which were not followed as observed during the survey.
Failure to Honor Dietary Preferences for a Resident
Penalty
Summary
A deficiency occurred when a resident with a physician's order specifying a renal diet with no onions was served a meal containing onions. The resident's admission record indicated a diagnosis of hypertension, and the Minimum Data Set showed intact cognition and a need for assistance during eating. Despite clear documentation in the physician's order and on the meal ticket that onions were not to be included, the resident's meal tray was observed to contain salisbury steak with brown gravy and slices of onions. During the observation, the Infection Preventionist Nurse confirmed that the meal ticket indicated no onions and acknowledged that the resident should not have received onions, as the resident did not like them and would likely not eat the meal. The DON also reviewed the physician's order and stated the importance of not serving onions to the resident. The facility's policy required that residents be offered food options that meet their nutritional needs and preferences, but this was not followed in this instance.
Unlicensed Medication Administration by CNA
Penalty
Summary
The facility failed to ensure that medication was administered by licensed staff, resulting in a deficiency related to medication administration for a resident. The incident involved a resident who was admitted with diagnoses including acute hematogenous osteomyelitis, unspecified peripheral vascular disease, and generalized muscle weakness. The resident was cognitively intact and required moderate assistance for daily activities. A physician's order prescribed nystatin powder to be applied topically to the resident's abdominal area. A Certified Nursing Assistant (CNA) was instructed by a Licensed Vocational Nurse (LVN) to administer the nystatin powder to the resident, despite the CNA not being trained or licensed to administer medication. The CNA followed the instruction and applied the medication, acknowledging that she was not aware of the medication's effects or side effects. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that medication administration is outside the scope of practice for CNAs and that they are not competent or trained for such tasks. The facility's policies and procedures clearly state that medications should only be administered by licensed personnel who are legally authorized to do so. The CNA's job description did not include medication administration, and the facility's policy on staffing emphasized the need for nursing staff to have the appropriate skills and competencies. The failure to adhere to these guidelines resulted in a potential medication error, highlighting a deficiency in ensuring that only licensed staff administer medications.
Unlicensed Medication Administration by CNA
Penalty
Summary
The facility failed to provide pharmaceutical services by not ensuring that a licensed staff member administered medication to a resident. This deficiency was identified during a review of the records and interviews with staff members. The incident involved a resident who was admitted with diagnoses including acute hematogenous osteomyelitis, unspecified peripheral vascular disease, and generalized muscle weakness. The resident was cognitively intact and required moderate assistance for daily activities. The deficiency occurred when a Certified Nursing Assistant (CNA) was instructed by a Licensed Vocational Nurse (LVN) to administer nystatin powder, a medication for fungal infections, to the resident's lower abdomen. The CNA, who was not trained or licensed to administer medication, followed the instruction and applied the medication. During interviews, the CNA acknowledged the mistake, stating that she was not aware of the medication's effects or side effects and should not have followed the LVN's instructions. Further interviews with the facility's Assistant Director of Nursing, Director of Staff Development, and Director of Nursing confirmed that medication administration is not within a CNA's scope of practice. The facility's policies and procedures also indicated that only licensed personnel are authorized to administer medications. The CNA's job description did not include medication administration, highlighting a clear breach of protocol and competency requirements.
Inaccurate Documentation of Physician Notification
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, leading to potential confusion in care. The resident was admitted with diagnoses including acute hematogenous osteomyelitis, unspecified peripheral vascular disease, and generalized muscle weakness. A review of the resident's medical records revealed discrepancies in the documentation of physician notification times. Specifically, the SBAR communication form indicated that the physician was notified at 12 a.m., which was inconsistent with the actual time of notification as stated by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The DON acknowledged that the documentation was inaccurate and explained that if staff did not manually enter the time of notification, the system defaulted to 12 a.m. This oversight occurred because staff failed to manually document the time they notified the physician, resulting in inaccurate records. The facility's policy on nursing documentation emphasized the importance of timely and accurate documentation, which was not adhered to in this instance.
Infection Control Breach Due to Non-Adherence to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA 1) who did not adhere to Enhanced Barrier Precautions (EBP) while providing care to a resident diagnosed with multi-drug-resistant organisms (MDROs). During an observation, CNA 1 was seen not wearing a gown while replacing the resident's blanket, despite the resident being on EBP. Additionally, CNA 1 did not perform hand hygiene after removing gloves and before handling clean linen, which is a critical step in preventing the spread of infections. The resident involved had a history of gallstones with acute cholecystitis and was readmitted to the facility with a requirement for EBP due to MDROs. The facility's policies on hand hygiene and EBP, which were last reviewed in January 2025, clearly state the necessity of wearing gowns during direct patient care for residents on EBP and performing hand hygiene before and after glove use. The Director of Nursing confirmed the importance of these practices to prevent infection spread, highlighting the deficiency in the facility's adherence to its own infection control protocols.
Failure to Obtain Proper Authorization for Bed Placement Against Wall
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, specifically regarding the placement of beds against walls without proper authorization and assessment. This deficiency was identified for six residents, where the facility did not obtain a physician's order, informed consent, or conduct a restraint assessment for the use of bed placement against the wall. The absence of these critical steps potentially restricted residents' freedom of movement and posed risks such as entrapment and physical harm. For Resident 137, the facility's records showed no physician's order, informed consent, or restraint assessment for the bed placement against the wall, despite the resident's inability to make decisions. Observations confirmed the bed was placed against the wall, creating a potential risk for entrapment. Interviews with staff, including an LVN and RN, confirmed that placing the bed against the wall was considered a restraint and required proper documentation and assessment to ensure safety. Similar deficiencies were noted for Residents 61, 131, 123, 132, and 42. Each resident's bed was placed against the wall without the necessary physician's order, informed consent, or restraint assessment. Staff interviews consistently indicated that the bed placement was intended to prevent falls but acknowledged it restricted residents' movement and required proper authorization and assessment. The facility's policy on restraints emphasized the need for evaluation and consent before applying any restraint, which was not adhered to in these cases.
Failure to Rotate Injection Sites for Insulin and Heparin
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards of care by not rotating the subcutaneous administration sites for insulin and heparin for four residents. This failure was identified during interviews and record reviews, which revealed that the same injection sites were repeatedly used for administering these medications. The facility's policy and procedure for insulin administration, as well as the manufacturer's guidelines for both insulin and heparin, clearly state the necessity of rotating injection sites to prevent adverse effects such as lipodystrophy, bruising, and localized cutaneous amyloidosis. Resident 29, who was admitted with diagnoses including type 2 diabetes mellitus, acute kidney failure, and acute osteomyelitis, was found to have insulin and heparin administered repeatedly in the same areas. The resident's care plan indicated the use of hypoglycemic and anticoagulant medications, but the administration records showed a lack of site rotation. Interviews with the RN and DON confirmed the oversight and acknowledged the potential risks associated with not rotating injection sites. Similarly, Residents 42, 402, and 134, all with diagnoses of diabetes and receiving insulin, experienced the same deficiency. Their medication administration records indicated repeated use of the same injection sites, contrary to the facility's policies and the manufacturer's guidelines. Interviews with nursing staff and the DON reiterated the importance of site rotation to prevent complications, yet the records showed consistent non-compliance with this standard practice.
Deficiencies in Resident Safety and Medication Management
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents. For one resident, medications including triamcinolone acetonide cream, travatan, bisacodyl, bromonidine tartrate, and dorzolamide HCl timolol maleate were found at the bedside without any orders or self-administration assessment. This posed a risk of overdose or access by other residents, as confirmed by the CNA and RN involved. The facility's policy requires that medications not authorized for bedside storage be reported and removed, which was not adhered to in this case. Another deficiency involved the improper use of fall mats for two residents. In one instance, a side table was placed on top of a fall mat, which could cause injury if the resident fell onto it. The LVN and DON confirmed that fall mats should be free of obstructions to prevent injury. Similarly, another resident's overbed table was placed on a floor mat, making it unstable and posing a fall risk. The facility's policy and the manufacturer's guidelines for floor mats were not followed, as they require the mats to be free of objects to reduce fall impact. Additionally, a resident was found standing over a wet floor due to a urine spill, increasing the risk of slipping and falling. The CNA and RN acknowledged that the floor should be dry and clutter-free to prevent falls. Furthermore, smoking materials were improperly stored at a resident's bedside, contrary to the facility's policy that requires such materials to be stored securely by staff. The DON confirmed that smoking materials should not be kept at the bedside to prevent fire hazards and accidental harm to other residents.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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