The Rowland
Inspection history, citations, penalties and survey trends for this long-term care facility in Covina, California.
- Location
- 330 W. Rowland Street, Covina, California 91723
- CMS Provider Number
- 056117
- Inspections on file
- 39
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at The Rowland during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow physician orders and internal policies for fall prevention for multiple residents. Two residents with intact cognition and significant medical conditions had active orders for bilateral floor mats, but observations showed no mats at their bedsides. Several residents who required assistance with ADLs experienced falls, including one with a documented forehead laceration, yet post-fall risk assessments were not completed as required. The DON reported that fall risk assessments are to be done on admission, periodically, and after a fall, and that residents with orders for floor mats must have them in place, but the records and observations did not reflect this practice.
Surveyors found that three residents receiving oxygen therapy did not receive safe and appropriate respiratory care. One resident with respiratory and heart failure had a nasal cannula that was not dated and was found touching the floor. Another resident with end-stage renal disease and peripheral vascular disease had an order for oxygen and MAR instructions to change and label oxygen tubing and the storage bag, but documentation showed the tubing was not changed, there was no oxygen care plan, and the nasal cannula was touching the floor without a storage bag at the bedside. A third resident with respiratory failure and dependence on supplemental O2 had an order interpreted by the IPN as requiring continuous oxygen, yet was repeatedly observed in a motorized wheelchair without oxygen, and the nasal cannula was later found hanging from a restroom doorknob and touching the floor. Facility policy and staff interviews confirmed that oxygen supplies were required to be dated, changed biweekly, stored in bags when not in use, and monitored by nursing staff, but these practices were not followed for these residents.
Surveyors found that meals were not prepared or served according to the approved menus on two consecutive lunch services. Residents received alternate items, such as pizza and other substituted foods, instead of the planned, dietitian-reviewed menu selections, and no advance notice of these changes was given to residents. The DSS was present in the kitchen but did not verify that the correct menu items were prepared or that meals matched physician orders, and residents were not informed of menu changes as required. The cook reported substituting available foods when ordered chicken did not arrive, did not notify the DSS, and admitted not reviewing or following the new menus, despite job descriptions and facility policy requiring adherence to established menus and limiting menu changes to the DSS and RD.
Surveyors found that two residents with ordered mechanically altered diets did not consistently receive food in the prescribed texture, and that staff did not reliably verify food consistency before trays left the kitchen. One resident on a mechanical soft/easy‑to‑chew diet was observed receiving hard broccoli, intact meat later cut by staff, and large pieces of fruit, which the resident reported were difficult to chew and swallow. Another resident with dysphagia on a minced and moist diet was served a whole cheese sandwich with bread edges, apple pie with crust, and soup containing bacon and vegetables, and reported that the food pieces were too large and not easy to swallow. CNAs stated that sandwiches arrived whole and were cut by nursing staff without clear guidance on size, while the Dietary Supervisor and DON confirmed that dietary staff were responsible for preparing correct textures and that both dietary and nursing staff were expected to check food consistency against facility policies for mechanical soft and minced and moist diets.
A resident with cerebrovascular disease, dysphagia, and vascular dementia, who required significant assistance with ADLs and was dependent for toileting, did not have a functioning call light in their room on multiple occasions. When the resident pressed the call light, it did not activate inside or outside the room, and the resident reported that staff did not respond when assistance was needed. An LVN and CNA stated that all staff were responsible for checking and answering call lights and that the system was essential for residents to request help, yet the CNA, who believed the call light had been checked and was working, confirmed during observation that it did not function. The DON stated that maintenance and nursing staff were responsible for ensuring call lights worked each shift, and facility policy required prompt response to call lights within 5–6 minutes.
Two residents did not have their IV site or TPN tubing properly labeled with the date, time, and initials as required by facility policy. One resident's peripheral IV site lacked labeling upon dressing change, and another resident's TPN tubing was not labeled when hung. Nursing staff and the DON confirmed these omissions during interviews and observations.
Multiple residents receiving oxygen therapy and respiratory treatments were found with equipment such as oxygen tubing, nebulizer tubing, and nasal cannulas in unsanitary conditions, including being placed on the floor or not stored in clean bags. In addition, required safety signage for oxygen use was not posted outside a resident's room. Staff interviews confirmed these practices were inconsistent with facility policy and infection control standards.
Two residents were placed on bedrails without documented safety assessments, physician orders, or informed consent, contrary to facility policy. One resident with cognitive impairment and another with intact cognition both had bedrails installed without attempts at alternatives or proper documentation, as confirmed by staff interviews and record reviews.
A nurse administered five scheduled medications to a resident with severe cognitive impairment and a feeding tube earlier than the prescribed time, outside the facility's allowed one-hour window. The DON confirmed that this practice was not in accordance with facility policy, which requires medications to be given within one hour before or after the scheduled time to ensure effectiveness.
A nurse administered five medications via gastrostomy tube to a resident with severe cognitive impairment and multiple diagnoses earlier than the scheduled time, resulting in a medication error rate of 17.86%, which exceeded the acceptable threshold. The facility's policy and the DON confirmed that medications should be given within a specific time window to prevent errors.
Surveyors found that a medication cart was left unlocked and unattended by an LVN, and a resident with COPD and other conditions was keeping prescribed inhalation medication in their bedside drawer without proper assessment or authorization. The DON and facility policies confirmed that medications must be secured and not kept at the bedside unless specific procedures are followed.
Surveyors identified that two of four kitchen sanitization buckets were not maintained at the correct chemical concentration, and required checks were not documented. Additionally, expired salsa containers were found in the refrigerator, and opened pasta noodles in dry storage were not labeled with open or use-by dates, contrary to facility policy. The Dietary Supervisor confirmed the importance of proper labeling and sanitization to ensure food safety.
Multiple residents requiring isolation or enhanced barrier precautions did not have proper signage or PPE carts outside their rooms, and staff failed to consistently use required PPE during care activities. A disposable gown was left hanging inside a room instead of being discarded, and the facility lacked a water management diagram to assess Legionella risk, all contrary to facility policy and orders.
A resident with severe cognitive impairment and total dependence for eating was assisted with meals by a CNA who stood over the resident rather than feeding at eye level, contrary to facility policy and staff expectations. Both the CNA and DON confirmed that feeding should occur at eye level to maintain dignity and proper monitoring.
A resident with hemiplegia and muscle weakness was found with their call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible on the resident's strong side. Staff confirmed the resident could not access the call light, resulting in a failure to accommodate the resident's needs.
A resident with significant medical conditions and moderately impaired cognition did not have an Advance Directive or AD Acknowledgement Form in their medical record. Staff interviews and policy review confirmed these documents should be present and updated with each admission or readmission, but they were missing from both the paper and electronic records.
A CNA was hired without a documented background check through the OIG database, contrary to facility policy requiring such checks to prevent employment of individuals with a history of abuse, neglect, or exploitation. Interviews with the DSD and DON confirmed the omission and the importance of pre-employment screening for staff and resident safety.
A resident with multiple chronic conditions and an indwelling Foley catheter was found with the catheter tubing not secured to the thigh, as required by facility policy and care plan. Both nursing staff and the DON confirmed the tubing was not properly attached, and the securement device was not taped, contrary to established procedures intended to prevent pulling and injury.
A resident with a biliary drain was found to have yellow biliary fluid leaking onto the floor beneath the drainage bag. Nursing staff acknowledged that the drainage bag should not be leaking, and the DON confirmed this posed an infection control concern. Facility policy required proper management of biliary drains to prevent such incidents.
A resident with multiple chronic conditions was receiving Lovenox for DVT prophylaxis when a consultant pharmacist recommended specifying a duration of therapy. The facility did not document that the attending physician was notified of this recommendation, contrary to policy, resulting in the recommendation not being addressed.
A resident with cognitive impairment and multiple diagnoses received antibiotics for a UTI without documented symptoms or meeting facility criteria, as required by the Antibiotic Stewardship Program. Staff interviews and record reviews confirmed the absence of necessary documentation and failure to follow established protocols for monitoring and documenting changes in condition.
A facility failed to follow its hand hygiene protocols when a CNA did not wash their hands after interacting with a resident diagnosed with C. diff. The resident was on contact isolation, requiring strict adherence to handwashing procedures. Despite removing protective gear, the CNA exited the room without washing hands, contrary to the facility's policy, which mandates handwashing with soap and water after contact with residents with infectious diarrhea.
Two residents in a LTC facility were found to have cigarettes and lighters in their possession, smoking unsupervised despite requiring supervision due to mental health and vision impairments. The facility failed to implement its smoking policy, creating potential fire hazards, especially with an oxygen machine present in one resident's room.
The facility failed to maintain safe food handling practices, with an ice scoop stored in a container with a brown liquid, leading to the distribution of contaminated ice to residents. Additionally, food storage practices were inadequate, with items not dated or labeled, increasing the risk of food-borne illnesses.
The facility failed to transmit MDS assessments within 14 days for 23 residents, as required. The Assistant Administrator, responsible for the task, did not realize the due dates, leading to the delay. Additionally, the facility had not trained other MDS staff on the transmission process, as per their policy.
The facility failed to provide proper care for GT management for two residents, leading to potential infection risks. One resident's GT tubing was left open, and another's GT site lacked a required dressing, contrary to care plans and facility policy.
The facility failed to manage oxygen therapy properly for several residents, as observed in unlabeled oxygen tubing and improper nasal cannula placement. This deficiency involved residents with conditions like COPD and respiratory failure, where oxygen tubing lacked date labels, risking infection, and nasal prongs were not correctly positioned, affecting oxygen delivery.
The facility failed to provide dialysis emergency kits for two residents requiring dialysis services, placing them at risk for excessive bleeding. Observations revealed the absence of these kits at the residents' bedsides, confirmed by nursing staff. The DON admitted the lack of policies to ensure kit availability.
The facility did not post accurate nurse staffing information in a prominent location, as required. Staffing details were found inside the North Nurses' Station, inaccessible to residents, family, and visitors. The Director of Staff Development was unaware of the requirement for accessible posting, leading to potential misinformation about staffing levels.
The facility failed to implement Gradual Dose Reductions (GDR) for two residents and did not limit PRN orders for psychotropic medications to 14 days for three residents. This oversight led to the potential inappropriate use of psychotropic drugs, affecting the residents' well-being. The facility did not adhere to its policy requiring PRN orders for antipsychotic medications to be reassessed every 14 days.
The facility failed to implement a comprehensive infection prevention and control program, lacking measures to monitor Legionella and other pathogens in water systems. Additionally, a resident with a Foley catheter was not provided with necessary Enhanced Barrier Precautions, such as signage and PPE, increasing the risk of infection.
A facility failed to include a resident's Advance Directive (AD) in their medical chart, despite the resident having both an AD and a POLST. The resident was alert and oriented, with intact cognitive abilities. Interviews with the Social Services Director and Director of Nursing revealed that the facility's policy required the AD to be prominently displayed in the medical record, which was not done, posing a risk of not honoring the resident's wishes.
A resident with dementia and epilepsy was left exposed during a bed bath by a CNA, who failed to follow the facility's policy of covering the resident and changing bath water as needed. The privacy curtain was open, and another CNA entered the room, further compromising the resident's privacy.
A facility failed to implement its policy on Translation and Interpretation services for a resident with limited English proficiency (LEP). The resident, who preferred Chinese, was communicated with by an LVN using body language, without a communication board at the bedside. The Activities Director confirmed the absence of necessary communication tools, which could lead to unmet needs.
A resident with a history of falls and requiring assistance with daily activities waited 31 minutes for help after activating the call light. Despite the facility's policy to respond within five to six minutes, staff interviews confirmed the delay, posing a risk of the resident attempting to move unassisted, potentially leading to a fall or injury.
A facility failed to implement interventions for a resident's positioning preference, potentially delaying wound healing. The resident, with a non-healing wound on the left ankle, preferred lying on her left side. Despite staff observations and interviews confirming this preference, care plans lacked interventions to manage it, contrary to the facility's wound care policy.
A resident with moderate cognitive impairment developed redness on her toes due to inadequate repositioning, despite having a care plan that included a pressure-reducing device and a turning program. Staff interviews confirmed the resident's preference to lie on her left side, and observations showed she remained in this position for extended periods, contrary to the facility's policy on pressure ulcer prevention.
A resident with spinal stenosis and bilateral artificial knee joints did not receive restorative services as ordered by the MD. The resident's Treatment Administration Record showed missed ambulation sessions, confirmed by staff interviews. This failure to follow the facility's policy on Restorative Services placed the resident at risk for contractures or a decline in ADL function.
A resident with a Foley catheter was not provided necessary care as per their care plan, which required the catheter to be secured to the inside of the thigh. Observations and staff interviews confirmed the catheter was not properly secured, contrary to facility policy, potentially leading to complications.
A resident with a fluid restriction order due to hyponatremia had their fluid intake improperly monitored, resulting in consistent overconsumption. Facility staff were unaware of the restriction and did not accurately measure fluid intake, contrary to the facility's policy requiring coordination between dietary and nursing staff.
A resident with multiple health conditions, including dementia and heart disease, received crushed enteric coated Aspirin due to an LPN's lack of awareness that such medications should not be crushed. The LPN routinely crushed the resident's medications because the resident could not swallow whole pills. The facility's policy required a reference list of medications not to be crushed, which was not followed.
The facility failed to maintain the required temperature in the Medication Refrigerator (MR) in Medication Storage Room 1, as observed by an LVN. The MR thermometer showed temperatures outside the acceptable range, and the LVN was unsure if the thermometer was broken. This non-compliance with the facility's policy could compromise medication effectiveness.
Failure to Implement Ordered Fall Prevention Measures and Post-Fall Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and its own policies for fall prevention. One resident admitted with respiratory and heart failure had a documented high fall risk score and a physician order for bilateral floor mats following a fall. Despite this, surveyors observed that the resident did not have bilateral floor mats at the bedside. The resident’s MDS and H&P showed intact cognition and a need for moderate to maximal assistance with ADLs. An LVN confirmed the resident had an order for bilateral floor mats due to a previous fall, stated that all residents with such orders should have mats at bedside, and acknowledged that the absence of mats created a risk of fall with injuries. Another resident with end-stage renal disease and peripheral vascular disease, who required varying levels of assistance with ADLs and had intact decision-making ability, also had an order for bilateral floor mats per the order summary report. During observation, this resident likewise did not have bilateral floor mats at the bedside. For two additional residents, records showed they had experienced falls, including one resident who sustained a forehead laceration. However, the facility did not complete post-fall risk assessments as required by its policies. One resident’s fall risk assessment documented a history of one or two falls and a moderate risk score, but this assessment was dated several weeks after the fall event. A fourth resident with hemiplegia and hemiparesis, intact cognition, and a need for assistance with multiple ADLs had a fall documented in an accident/incident report. The most recent fall risk assessment prior to that fall showed no history of falls and a moderate risk score, and there was no evidence of a fall risk assessment completed after the fall. The DON stated that fall risk assessments are to be completed on admission, quarterly, annually, and after a fall, and that residents at risk for falls are monitored and care planned with interventions. The DON also stated that residents must have floor mats if there is an order for them. Facility policies on fall risk assessment, assessing falls and their causes, and carrying out physician orders required review of fall history, completion of a fall risk assessment after a fall, documentation of appropriate interventions, and ensuring all physician orders are carried out safely and accurately, which did not occur for these residents.
Failure to Maintain Safe Oxygen Administration and Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate oxygen administration and infection prevention practices for three residents receiving oxygen therapy. For one resident with respiratory failure and heart failure, surveyors reviewed the admission record, history and physical, MDS, and oxygen orders, which showed the resident required supplemental oxygen at 2 L/min to maintain oxygen saturation above 91%. During observations in the resident’s room on two separate days, the resident’s nasal cannula was found not labeled with an open date and was touching the floor. In a concurrent interview, the Infection Preventionist Nurse (IPN) stated that nasal cannulas should be labeled with the date opened for infection prevention and acknowledged there was no way to know when or if the nasal cannula had been changed because it was not dated. For a second resident with end-stage renal disease and peripheral vascular disease, the order summary indicated an order for oxygen at 3 L/min to maintain oxygen saturation above 92%. The MAR directed staff to change and label oxygen tubing and the plastic bag every night shift starting on the last day of the month and ending on the last day of the month, but documentation from the beginning of the month through the survey date showed the oxygen tubing had not been changed. The resident’s electronic medical record did not contain a care plan for oxygen administration. During an observation and interview in the resident’s room, the resident did not have a bag at the bedside for oxygen equipment, and the nasal cannula was touching the floor. The IPN stated that residents required a bag for their oxygen equipment for infection control and that when residents were not using the nasal cannula, it must be placed in the bag to prevent contamination with germs. For a third resident with respiratory failure and dependence on supplemental oxygen, the order summary showed an order for oxygen at 2 L/min three times a day for shortness of breath. The MDS and history and physical indicated the resident had intact decision-making capacity and required varying levels of assistance with ADLs. During two separate observations, the resident was seen using a motorized wheelchair without receiving oxygen. In a record review and interview, the IPN interpreted the order for oxygen three times a day to mean the resident required continuous oxygen and that all three shifts had to monitor continuous oxygen use; the IPN stated the resident should not be without oxygen, even when using the motorized wheelchair. In a subsequent observation in the resident’s room, the nasal cannula was found hanging from the restroom doorknob and touching the floor. The IPN stated this was not acceptable practice because the nasal cannula had to be placed in a bag and not touch the floor, and that the cannula could not be reused because it was contaminated. The facility’s policy on oxygen administration/respiratory supply required all residents on oxygen to be monitored by nursing staff, all oxygen supplies to be changed biweekly with date and time documented, and all supplies not in use to be placed in a bag for infection prevention control. Additional interviews with the IPN and the DON confirmed the facility’s expectations and policies regarding oxygen equipment management and infection prevention. The IPN stated that for residents receiving oxygen, nursing staff must label nasal cannulas with the open date, place nasal cannulas in a bag when not in use, avoid allowing tubing to touch the floor, and change oxygen equipment weekly or biweekly. The IPN stated that not dating oxygen cannulas meant staff would not know if the equipment was old and that this could potentially cause an infection. The DON stated that residents on oxygen should have a care plan because oxygen administration is a lifesaving issue and that such a care plan would outline interventions such as checking pulse, following the physician’s oxygen order, placing oxygen tubing in a bag when not in use, and changing oxygen tubing every two weeks. The DON also stated that nursing staff were required to label oxygen equipment with the open date, change equipment every two weeks, and place unused equipment in a bag, and that all staff were responsible for ensuring infection prevention practices were followed and that residents were continuously receiving oxygen as ordered.
Failure to Follow Approved Menus and Notify Residents of Meal Changes
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure that meals were prepared and served according to the approved dietary menus for two consecutive lunch meals. On one day, residents were observed receiving meat, salad, and broccoli instead of the scheduled chicken cacciatore, garlic noodles, sautéed squash, French bread with margarine, and ice cream listed on the Spring Week Seven menu. On the following day, residents were served pizza and salad instead of the planned country fried steak with gravy, mashed potatoes, seasoned peas, and cherry cheesecake. These deviations from the planned menus occurred without adherence to the facility’s established menu and without documented, dietitian-reviewed substitutions. Interviews with the Dietary Services Supervisor (DSS) and the cook revealed that the DSS had provided menus and food spreadsheets to dietary staff and expected them to be followed for every meal, but the DSS did not verify that the correct menu items were prepared before food left the kitchen. The DSS stated they were present in the kitchen while the cook prepared meals but did not check what was being served and were not aware of the daily menu items for those days. The DSS acknowledged that they did not monitor dietary staff, did not ensure meals were served according to physician orders, and did not know what food was served on one of the days in question. The DSS also stated that residents were supposed to be notified of menu changes two to three hours before mealtime, but residents were not notified of the changes on either day. The cook reported that the chicken ordered for the scheduled meals did not arrive on time, and in response, the cook independently decided to serve pizza and other available items from the refrigerator instead of the planned menu items. The cook stated they did not notify the DSS of these changes, believed they were allowed to make menu changes without notifying the DSS, and admitted they had not reviewed the new menus received a month earlier, despite being expected to follow them that week. The DON stated that only the DSS and registered dietitians were authorized to make menu changes, that nursing staff must be informed so residents can be notified, and that residents did not receive the correct nutritional value because the dietary menu and food spreadsheets were not followed. Review of job descriptions and the facility’s “Menu Substitutions” policy confirmed that the Director of Food and Nutrition Services is responsible for supervising meal preparation according to established menus and that menu substitutions must be from the same food group as the omitted item, and that cooks are required to prepare food according to the facility menu and follow instructions from the DSS.
Failure to Provide Ordered Texture‑Modified Diets and Verify Food Consistency Before Service
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed texture‑modified diets and to ensure appropriate texture checks before food left the kitchen for two residents with ordered mechanically altered diets. For the first resident, who had respiratory failure and heart failure and was care planned for a therapeutic diet with monitoring for signs of swallowing difficulty, the clinical record showed an order and nutrition note for a mechanical soft/easy‑to‑chew diet. Despite this, surveyors observed the resident receiving meat and broccoli that were not in a mechanical soft consistency. The resident reported that meat was served in one piece and only cut into smaller pieces by staff, and that the broccoli was hard rather than soft, requiring prolonged chewing to swallow. On another observation, the resident was served grapes cut in half with skins on and melon cut in rectangular pieces, which the resident stated looked too large and declined to eat. The second resident had cerebrovascular disease, dysphagia, and vascular dementia with fluctuating decision‑making capacity, and was care planned for a therapeutic, mechanically altered diet with monitoring for pocketing, choking, coughing, drooling, and multiple swallowing attempts. The record documented an order for a minced and moist diet three times daily. However, surveyors observed this resident receiving a whole cheese sandwich with bread edges, apple pie with crust, and vegetable soup with bacon and carrots. The resident stated that the sandwich was cut into pieces by nursing staff but the pieces were still large and not easy to swallow, and that food provided was not easy to chew and was not cut into small pieces as needed for their condition. Staff interviews further described how these incorrect textures reached the residents. The Dietary Supervisor stated that a mechanical soft diet should consist of soft, easy‑to‑chew foods, with broccoli chopped into small pieces, and that a minced and moist diet required food to be wet, ground, and finely minced, with apple pie and bread edges not acceptable due to chewing difficulty. The facility’s policies for Level 7 Regular Easy to Chew and Level 5 Minced and Moist specified that meats should be chopped into 1/2‑inch or smaller or minced to 2–4 mm, moist, and cohesive, and that hard, sticky, or crunchy foods were excluded. The Dietary Supervisor acknowledged that dietary staff, including the supervisor, were responsible for checking food texture before trays left the kitchen. CNAs reported that sandwiches arrived whole from the kitchen and were cut by CNAs into bite‑size pieces without clear guidance on the required size, and that some items, such as pie, were too hard and needed further cutting. The DON stated that therapeutic diets were ordered for resident safety, that dietary staff were responsible for providing the correct texture, and that nursing staff were responsible for checking all residents’ food before delivery, underscoring that correct food texture was important to prevent choking.
Failure to Ensure Functioning Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a working call light system for a sampled resident in their room and associated areas. The resident had cerebrovascular disease, dysphagia, and vascular dementia with fluctuating capacity, but was assessed on the MDS as having intact cognitive skills for daily decision-making and requiring varying levels of assistance for ADLs, including maximal assistance for showering/bathing and lower body dressing, and dependence for toileting hygiene and footwear. On two separate observations, when the resident pressed the call light in their room, the call light did not activate inside or outside the room, and the resident reported that staff did not come to assist when he used the call light and that he needed help with his lunch. Staff interviews confirmed expectations that all staff were responsible for answering and checking call lights, and that the call light system was the primary means for residents to communicate their need for assistance. An LVN stated that staff were responsible for ensuring call lights were working and that a functioning call light was important for resident communication and safety. A CNA reported that he checked residents’ call lights at the start of his shift and believed this resident’s call light was working, but when observed pressing the call light in the resident’s room, it again failed to activate, and the CNA acknowledged unawareness that it was not working and stated there was a potential for the resident not receiving needed assistance. The DON stated that maintenance was responsible for checking call lights and nursing staff were to check them every shift, and that if call lights were not working, residents’ needs would not be met. The facility’s call light policy indicated that call lights were to be answered within 5 to 6 minutes without undue delay.
Failure to Label IV and TPN Sites and Tubing per Policy
Penalty
Summary
The facility failed to adhere to professional standards of practice for infusion therapy in the care of two residents. For one resident with a history of gangrene and peripheral vascular disease, the peripheral intravenous (IV) site was not labeled with the date and initials upon insertion or dressing change, as required by facility policy. This omission was confirmed during observation and interview with nursing staff, who acknowledged that the labeling was necessary for infection control and to track when the dressing was last changed. The resident's care plan and facility policy both specified the need for dating and initialing the IV site dressing. For another resident receiving total parenteral nutrition (TPN) through a central venous catheter due to diagnoses including bladder cancer and anemia, the TPN administration set was not labeled with the date and time when it was hung. Observation and interviews with nursing staff and the DON confirmed that the tubing was unlabeled, contrary to facility policy, which required labeling to ensure proper infection control and to document when the tubing was last changed. Both deficiencies were identified through direct observation, record review, and staff interviews.
Failure to Maintain Safe and Sanitary Respiratory Care Practices
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents requiring oxygen therapy and related respiratory equipment. For one resident with pulmonary fibrosis and diabetes, observations revealed that both the oxygen tubing and nebulizer tubing were found on the floor, and a CNA confirmed that the tubing had become contaminated due to contact with the floor. The Director of Nursing (DON) acknowledged that such contamination poses an infection control risk, as equipment on the floor is considered contaminated and could be a source of infection for the resident. Another resident with a history of lung cancer, pneumonia, and chronic kidney disease was observed with oxygen nasal prongs not properly placed in the nostrils, and the nebulizer face mask was left on the bedside table instead of being stored in a clean bag. The DON and a nurse both stated that the nasal prongs should be in the nostrils to ensure the resident receives the prescribed oxygen, and the nebulizer mask should be stored in a clean bag to prevent contamination. Additionally, a resident with asthma and hypertension was found to be receiving oxygen therapy without the required "Oxygen No Smoking, No Open Flames" sign posted outside the room, contrary to facility policy and staff statements regarding fire safety. A further observation involved a resident with diabetes and chronic kidney disease, where the nasal cannula was found on the floor with the prongs directly touching the surface. Nursing staff confirmed that the cannula should be stored in a plastic bag when not in use to prevent cross-contamination. The facility's policy and procedure on oxygen administration and respiratory supply require that all supplies not in use be placed in a bag for infection control, and that appropriate signage be posted when oxygen is in use. These deficiencies were identified through direct observation, staff interviews, and review of facility records and policies.
Failure to Follow Bedrail Assessment and Consent Procedures
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of bedrails for two residents. For one resident with dementia, Alzheimer's disease, and moderately impaired cognition, full bedrails were observed in use without any documented assessment for safety risk, physician's order, or informed consent prior to installation. The resident was dependent on staff for most activities of daily living, and staff confirmed that the required assessment and documentation were not completed before applying the bedrails. For another resident with anxiety disorder and muscle weakness, both upper side rails were found raised, and the resident reported never being asked for consent regarding their use. The resident had intact cognitive skills and required some assistance with daily activities. Facility staff, including the DON, confirmed that no alternatives were attempted, no physician's order was obtained, and no informed consent was documented before the bedrails were installed. The facility's policy required assessment, consideration of alternatives, and consent prior to bedrail use, but these steps were not followed for either resident.
Medications Administered Outside Prescribed Time Window
Penalty
Summary
A deficiency occurred when a licensed vocational nurse administered five scheduled medications to a resident through a gastrostomy tube earlier than the prescribed time. The medications, which included Tylenol Extra Strength, Ferrous Sulfate Liquid, Folic Acid, Sertraline, and Docusate Sodium, were all scheduled for 9:00 a.m. but were given at 7:45 a.m. The nurse acknowledged that administering medications outside the scheduled time could affect their effectiveness. The facility's policy allows for medications to be given within one hour before or after the scheduled time, but this administration was outside that window. The resident involved had significant medical needs, including paraplegia, depression, dementia with severely impaired cognition, and was dependent on staff for all activities of daily living. The resident received nutrition via a feeding tube. The Director of Nursing confirmed that medications should be administered within the specified time frame to ensure therapeutic effectiveness and avoid potential harm, as outlined in the facility's policy.
Medication Error Rate Exceeded Due to Early Administration
Penalty
Summary
The facility failed to maintain a medication error rate at or below five percent during medication administration for one resident. On the observed date, a licensed vocational nurse administered five medications via gastrostomy tube to a resident with severe cognitive impairment, paraplegia, depression, and dementia. All five medications were scheduled for administration at 9 a.m., but the nurse administered them at 7:45 a.m., which was earlier than the prescribed time. The nurse acknowledged that administering medications outside the scheduled time could affect their effectiveness and that it was important to follow the correct timing to prevent medication errors. A review of the resident's records confirmed the resident's dependence on staff for all activities of daily living and the use of a feeding tube for nutrition. The facility's policy required adherence to the five rights of medication administration, including the right time. The Director of Nursing confirmed that medications should be given within one hour before or after the scheduled time and that deviations could result in medication errors. This incident resulted in five medication errors out of twenty-eight opportunities, leading to a medication error rate of 17.86%.
Failure to Secure Medications and Improper Resident Medication Storage
Penalty
Summary
Surveyors observed that a medication cart containing residents' medications was left unlocked and unattended in a hallway by a Licensed Vocational Nurse (LVN) during a medication pass. The LVN admitted to not locking the cart when retrieving medication from the medication room, acknowledging that the cart should have been secured for safety. The Director of Nursing (DON) confirmed that the medication cart needed to be locked if it was outside the licensed nurse's view. Facility policy and procedure documents reviewed by surveyors also required absolute security of medications, including locking medication carts when out of sight. Additionally, a resident with diagnoses including hypertension, depression, and chronic obstructive pulmonary disease (COPD) was found to have a prescribed inhalation medication stored in their bedside drawer. The resident stated they kept their medication in the drawer, and the LVN confirmed this, stating that medications should not be kept at the bedside for safety reasons. The DON stated that residents were not allowed to have medication at their bedside unless they had been assessed for safe self-administration. Facility policy required written physician orders and interdisciplinary committee determination for residents to self-administer or retain medications in their rooms.
Deficient Food Handling and Storage Practices Identified
Penalty
Summary
The facility failed to maintain safe food handling practices in several areas, as observed during a survey. Two out of four red sanitization buckets used in the kitchen were not maintained at the correct chemical concentration, as required by the manufacturer's guidelines of 200-400 ppm. Additionally, the log for checking the sanitizer concentration showed that the required check at 8:00 a.m. was not performed. The Dietary Supervisor confirmed that these buckets are used to sanitize kitchen surfaces. Further deficiencies were observed in food storage and labeling. One plastic container of expired red tomato salsa and one container of green salsa, both past their use-by dates, were found in the walk-in refrigerator. In the dry storage area, an open bag of penne pasta noodles and an open bag of spaghetti pasta noodles were not labeled with an open date or use-by date. The facility's policies require that leftover or opened foods be labeled and dated to ensure proper use and safety. The Dietary Supervisor acknowledged the importance of these practices to prevent serving expired or unsafe food.
Failure to Implement and Communicate Infection Control Precautions
Penalty
Summary
The facility failed to implement and follow infection prevention and control procedures for multiple residents requiring isolation or enhanced barrier precautions (EBP). For one resident with a Stage 3 pressure injury, there was no EBP signage or isolation cart with personal protective equipment (PPE) outside the room, despite physician orders and care plan interventions requiring these measures. The Infection Prevention Nurse confirmed that signage and PPE carts should have been present to ensure staff compliance with EBP protocols. Another resident with a gastrostomy tube and severely impaired cognition was observed receiving medication administration from an LVN who did not don a gown, as required under EBP. The LVN acknowledged the omission and stated that a gown should have been worn to prevent cross-contamination. Additionally, a resident with a biliary drain and central line did not have EBP signage posted outside the room, despite orders and facility policy indicating that such signage is necessary to communicate required precautions to staff and visitors. Further deficiencies included a disposable gown left hanging on the doorknob inside the room of a resident on contact isolation for a multidrug-resistant organism (MDRO), contrary to facility policy that requires immediate disposal of used gowns. The facility also lacked a water management program with a diagram or text assessing where Legionella or other waterborne pathogens could grow, as required by their own policy. These failures were confirmed through staff interviews and review of facility policies and procedures.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
Staff failed to promote dignity while assisting a resident with meals by not feeding the resident at eye level to maintain face-to-face contact. The resident, who had diagnoses including Parkinson's disease, dementia, and diabetes mellitus, was admitted with severely impaired cognition and required total assistance with eating. During an observation, a CNA was seen standing over the resident while providing feeding assistance, rather than sitting at eye level as required by facility policy and best practices for maintaining resident dignity. Interviews with the CNA and the DON confirmed that staff are expected to feed residents at eye level to allow for proper monitoring and to uphold the resident's dignity. The facility's policy on meal assistance specifically states that residents should not be fed while staff are standing over them, emphasizing the importance of safety, comfort, and dignity during mealtimes. The failure to follow this policy was directly observed and acknowledged by staff.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with hemiplegia affecting the right dominant side, muscle weakness, and anxiety was found with their call light on the floor and out of reach. The resident's care plan specified that the call light should be kept within reach, particularly on the side of the resident's strong arm and hand. During observation, the resident was lying in bed with a contracted right hand, and the call light was not accessible. Certified Nurse Assistant 3 confirmed that the resident could not reach the call light and acknowledged it should have been placed within reach of the resident's functional side. Further review of the resident's records indicated that the resident was dependent on staff for activities of daily living and had intact cognition. The facility's policy and procedures required that call lights be kept within reach of residents at all times. The Director of Nursing also stated that the call light should be placed close to the resident's good arm and hand to ensure timely response to needs. The failure to keep the call light within reach was contrary to both the care plan and facility policy.
Failure to Maintain Advance Directive Documentation in Resident Record
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive (AD) and AD Acknowledgement Form were present in the medical record for one of three sampled residents. Upon review of the resident's admission record, it was found that the resident, who had a history of malignant neoplasm of the lung, pneumonia, and chronic kidney disease, did not have a copy of the AD or the AD acknowledgement form in either the paper chart or the electronic medical record. The resident's Minimum Data Set indicated moderately impaired cognition and a high level of dependence on staff for daily activities. Interviews with the RN Supervisor and the DON confirmed that the AD and AD acknowledgement form should be updated and included in the resident's chart with each admission or readmission. The facility's policy also required that residents be provided with information about their rights regarding medical treatment and advance directives upon admission, and that this information be prominently displayed in the medical record. The absence of these documents in the resident's record was verified during the survey process.
Failure to Complete Required Background Check Prior to Hire
Penalty
Summary
The facility failed to conduct a required background check for one of two randomly selected employees, a Certified Nurse Assistant (CNA), prior to hire as mandated by the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy. During a review of the CNA's employee file, there was no documented evidence that the Office of Inspector General (OIG) database check or any background check was completed before or after the CNA's hiring date. Interviews with the Director of Staff and Development and the Director of Nursing confirmed that background checks are necessary for staff and resident safety, and that the administrator was responsible for performing these checks prior to employment. The facility's policy requires that no individual with a history of abuse, neglect, exploitation, or misappropriation be employed, but this process was not followed in this instance.
Foley Catheter Tubing Not Secured as Required by Facility Policy
Penalty
Summary
A deficiency was identified when a resident with a Foley catheter was observed with the catheter tubing not secured to the thigh, contrary to the facility's policy and procedure. The resident, who had diagnoses including type 2 diabetes mellitus, hypertension, and chronic kidney disease, was dependent on staff for most activities of daily living and required an indwelling Foley catheter for urinary retention and skin management. The care plan specified that staff should monitor the position of the catheter tubing to ensure proper urine flow, and the order summary required licensed staff to check every shift that the catheter was in place. During observation and interviews, it was confirmed by both a registered nurse and the Director of Nursing that the catheter tubing was not secured as required, and the securement device was not taped. The facility's policy indicated that the tubing should be attached to the resident's leg to prevent pulling and injury. This failure to follow established procedures had the potential to result in catheter-related complications for the resident.
Failure to Prevent Biliary Drainage Leak and Maintain Infection Control
Penalty
Summary
A deficiency occurred when a resident with a biliary drain was found to have biliary fluid on the floor beneath their drainage bag. The resident, who had diagnoses including bladder cancer and anemia, required substantial to maximal assistance for mobility and had an order in place to monitor and document biliary drain output three times daily. Documentation showed the drain output was being recorded, but during an observation, yellow liquid from the biliary drain was seen on the floor. The LVN present confirmed that each nurse is responsible for emptying the drainage bag during their shift and acknowledged that the drainage should not be leaking onto the floor. The Director of Nursing confirmed that biliary fluid should not be present on the floor due to infection control concerns, as organisms in the fluid could be a source of illness or infection and could be transmitted by contact. The facility's policy on biliary drain management emphasized the importance of proper care to prevent infection and ensure appropriate drainage. The failure to prevent biliary drainage from leaking onto the floor constituted a lapse in infection control practices for the resident requiring biliary drain care.
Failure to Act on Pharmacist's Medication Regimen Review Recommendation
Penalty
Summary
The facility failed to act upon a consultant pharmacist's medication regimen review (MRR) recommendation for a resident who was receiving Enoxaparin Sodium Injection (Lovenox) for deep vein thrombosis prophylaxis. The pharmacist's MRR specifically recommended that a duration of therapy be provided for the use of Lovenox. However, there was no documentation that the attending physician was notified of this recommendation, as confirmed by both a Licensed Vocational Nurse and the Director of Nursing during interviews and record reviews. The resident involved had a medical history including osteomyelitis, diabetes mellitus, and chronic obstructive pulmonary disease, and required varying levels of assistance with activities of daily living. The facility's policy and procedure required that the consultant pharmacist's findings and recommendations be reported to the physician and documented accordingly, but this process was not followed in this instance. As a result, the pharmacist's recommendation regarding the medication regimen was not communicated or acted upon.
Failure to Follow Antibiotic Stewardship Policy for UTI Treatment
Penalty
Summary
The facility failed to implement its policy on antibiotic use and change in condition for one of five sampled residents, resulting in the administration of antibiotics without meeting established criteria. A resident with diagnoses including Alzheimer's disease, dementia, and depression was admitted and later had an abnormal urinalysis. Subsequently, a physician ordered Cephalexin for a urinary tract infection, and the medication was administered for ten days. However, the resident's medical record did not document any of the required signs or symptoms of a symptomatic UTI as outlined in the facility's Infection Criteria Checklist, and there was no urinary catheter in place. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that the necessary documentation of UTI signs and symptoms was not present in the resident's record. Both staff members acknowledged the importance of completing infection criteria and tracking to ensure appropriate antibiotic use and compliance with the facility's Antibiotic Stewardship Program. Review of facility policies indicated that changes in resident condition and antibiotic use should be thoroughly documented and tracked, but these procedures were not followed in this case.
Failure to Adhere to Hand Hygiene Protocols for C. diff Isolation
Penalty
Summary
The facility failed to implement its Policy and Procedure (P&P) on Handwashing and Hand Hygiene, specifically in the case of a certified nursing assistant (CNA 1) who did not wash their hands after interacting with a resident diagnosed with Clostridium difficile (C. diff) infection. This resident, identified as Resident 3, was admitted with end-stage renal disease and enterocolitis due to C. diff. The care plan for Resident 3 included contact isolation precautions to prevent the spread of infection, which required staff to adhere to strict hand hygiene protocols. During an observation, CNA 1 was seen moving Resident 3's overbed table and adjusting bed linens without washing their hands afterward. Despite removing their isolation gown and gloves, CNA 1 exited the room without performing hand hygiene, only washing their hands at the nurses' station sink. This action was contrary to the facility's P&P, which mandates handwashing with soap and water after contact with residents with infectious diarrhea, such as C. diff, before exiting the isolation room. Interviews with other CNAs and the Infection Prevention Nurse (IPN) confirmed the necessity of handwashing before exiting the room of a resident on contact isolation. The IPN emphasized that handwashing with soap and water is recommended over alcohol-based hand sanitizers to prevent the spread of C. diff. The facility's P&P on Handwashing and Hand Hygiene clearly outlines these procedures, highlighting the importance of hand hygiene as a primary means to prevent infection spread.
Failure to Implement Smoking Policy and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents who were smokers. Resident 8, who was on Seroquel for paranoid schizophrenia and had a history of hearing voices telling him to harm himself and others, was found to have cigarettes and lighters in his room. He smoked unsupervised, contrary to the facility's smoking policy, which required staff supervision due to his mental health condition. The Director of Nursing (DON) was unaware of Resident 8's possession of smoking materials and confirmed that he had not been evaluated for safe smoking practices. Resident 36, who had poor vision and was legally blind, also had cigarettes and lighters in her possession and smoked without supervision. Her care plan indicated she required supervision due to her impaired vision and the presence of an oxygen machine in her room, which posed a significant fire hazard. Despite these risks, Resident 36 was allowed to keep smoking materials and was not monitored during smoking, as required by her care plan and the facility's smoking policy. The facility's failure to implement its smoking policy and ensure proper supervision of these residents created a potential for serious harm, including fire hazards, due to the presence of smoking materials in the residents' rooms. The survey team identified these deficiencies during their investigation, highlighting the facility's noncompliance with safety protocols for residents who smoke.
Removal Plan
- Cigarettes and cigarette lighters were removed from Resident 8 and Resident 36's rooms and placed under supervision of the charge nurses (Licensed Vocational Nurses [LVNs] and Registered Nurses [RNs]).
- Resident 8 and Resident 36's CPs were updated by LVNs and the DON.
- Resident 8 and Resident 36 were educated by the facility's DON on smoking and cigarette lighter safety and why cigarette lighters cannot be in residents' possession.
- Resident 8 was informed by the ADM for safety and importance of using appropriate and approved ashtrays for cigarette butts (the part of the cigarette that was left after it had been smoked).
- The Supervised Designated Smoking Area Map for smokers was created which included the following: a. Patio in front of the facility by the front entrance. b. Patio outside the facility by the back entrance/parking lot. c. Patio outside the facility exit located between rooms [ROOM NUMBERS].
- The Designated Smoking Time Schedule for residents who required smoking supervision was created which included the following: a. Morning after breakfast from: 8:00 am to 8:30 am, 9:00 am to 9:30 am and 11:30 am to 12:00 pm b. Afternoon after lunch from: 1:00 pm to 1:30 pm, 2:30 pm to 3:00 pm and 4:30 pm to 5:00 pm c. Evening after dinner from: 6:00 pm to 6:30 pm
- The Director of Staff Development (DSD) provided an in-service to 26 Certified Nursing Assistants (CNAs), nine LVNs, four RNs, one Social Services Designee, one Medical Records Designee, three activity staff, and one housekeeper on the facility's revised smoking policies regarding supervised smoking, designated smoking areas, and designated smoking time schedules.
Deficient Food Handling and Storage Practices
Penalty
Summary
The facility failed to maintain safe food handling practices, specifically in the storage and sanitation of an ice scoop and its container. The ice scoop was stored in a container that contained approximately 100 milliliters of a brown liquid substance, which the scoop was in contact with. This contaminated scoop was used by Certified Nursing Assistants (CNAs) to fill ice chests that were distributed to the North and South Nursing Stations, affecting 42 out of 90 residents who received ice during breakfast and lunch. The facility had no records of cleaning and sanitizing the ice scooper container as per their policy. Additionally, the facility did not ensure safe food storage practices. In one of the kitchen freezers, food items were not dated when received, and mixed salad dressings were not discarded after their indicated shelf life. In the kitchen's dry and canned storage area, food items were also not dated, and in one of the unit refrigerators, stored food items were not labeled with the resident's name and date. These practices placed residents at risk for food-borne illnesses. The survey team identified an Immediate Jeopardy situation due to the facility's failure to meet food safety standards, specifically regarding the storage of food equipment in a sanitary condition. The ice scoop and container were not cleaned and sanitized daily, as required by the facility's policy. This oversight led to the distribution of contaminated ice to residents, posing a risk of water-borne illnesses.
Removal Plan
- The ice scoop and ice scoop container were placed in the kitchen dishwasher to be cleaned and sanitized.
- The two ice chests in the north and south nursing stations were sanitized.
- The ice machine located in the facility's dining room was locked and put into temporary out of service.
- All residents' water pitchers and cups for 90 residents (total census) were replaced with new/uncontaminated water pitchers and cups.
- The Dietary Supervisor (DS) in-serviced four dietary aides on the cleaning of the ice scooper and ice scooper container.
- 200 pounds of ice was purchased by the ADM.
- A new ice scooper and container sanitation log was created for the dietary aides on duty to log in the time of the day when they sanitize the ice scooper and the ice scooper container. The DS would check the log to ensure the ice scooper and the ice scooper container were sanitized daily.
- A water company service had been contracted and scheduled maintenance of the ice machine and replacement of water filter every six months.
- The facility's (P&P) titled, Cleaning and Sanitizing the Ice Scooper and Container for Ice Machine, was revised to include daily cleaning of the ice scooper, the ice scooper container and document in the cleaning log.
- A new clear ice scooper container with lid and new ice scooper was purchased.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to transmit assessments within 14 days of completion for 23 sampled residents. This deficiency was identified during a review of the Minimum Data Set (MDS) 3.0 Final Validation Report, which showed that the assessments for these residents were submitted late. The MDS Nurse indicated that the Assistant Administrator (AADM) was responsible for transmitting the MDS assessments to the Centers for Medicare and Medicaid Services (CMS). However, the AADM admitted to not realizing the due dates for these assessments, resulting in the delay. The AADM further acknowledged that the facility had not provided training to other MDS staff on how to transmit MDS assessments to CMS. The facility's policy and procedure, which was undated, stated that MDS staff were responsible for timely transmission of MDS data in accordance with the MDS RAI Instruction Manual. The failure to transmit these assessments on time had the potential to result in inaccurate information being submitted to CMS, which could affect the facility's star rating and quality of care.
Deficiencies in Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide necessary care and services for gastrostomy tube (GT) management for two residents, leading to potential risks of infection and adverse consequences. For Resident 193, who was admitted with diagnoses including subdural hemorrhage and epilepsy, the GT tubing was observed with the end open and hanging on a pole, contrary to the care plan that required it to be capped to prevent infection. This was confirmed by interviews with the Licensed Vocational Nurse, Registered Nurse Supervisor, and Director of Nursing, all of whom acknowledged the need for the tubing to be covered to maintain the quality of the feeding formula and prevent contamination. Similarly, for Resident 195, who had diagnoses including senile degeneration of the brain and altered mental status, the GT site was found without a cover or dressing, despite the care plan's requirement for daily cleaning and dressing to prevent infection and skin irritation. The Infection Preventionist Nurse and Director of Nursing confirmed that the site should be covered as ordered to protect the skin and prevent accidental pulling during movement. The facility's policy on enteral feedings also emphasized the importance of securing the tube and applying a new dressing as per physician orders.
Deficiency in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide necessary care and services for residents on oxygen therapy as ordered by the physician, as indicated in the residents' plan of care and in accordance with the facility's Policy and Procedure on Oxygen Administration. This deficiency was observed in four residents who were receiving oxygen therapy. The facility did not label the oxygen tubing with the date it was changed or started, which is crucial for infection control and ensuring the tubing is changed on schedule. This oversight was noted in the cases of Residents 189, 31, and 2, where the oxygen tubing lacked proper labeling, potentially leading to bacterial growth and infection. Resident 189, admitted with conditions including hypertension and morbid obesity, was observed with oxygen tubing that was not labeled with the date of change. Similarly, Resident 31, who had diagnoses including congestive heart failure and respiratory failure, also had unlabeled oxygen tubing. Interviews with the Registered Nurse Supervisor and the Infection Preventionist Nurse confirmed the necessity of labeling the tubing to prevent infection. Resident 2, diagnosed with chronic obstructive pulmonary disease, had an oxygen concentrator with coiled tubing in a plastic bag, also lacking a date label, which was acknowledged by the Registered Nurse Supervisor as a risk for bacterial growth. Additionally, Resident 64, who was dependent on supplemental oxygen due to chronic respiratory failure, was found with nasal prongs improperly positioned under the chin, rather than in the nostrils, during an observation. This improper placement meant the resident was not receiving the prescribed amount of oxygen. The Registered Nurse Supervisor admitted to not checking the proper placement of the nasal prongs during rounds. The facility's policy indicated that nasal cannula should be properly positioned and monitored by licensed nurses, which was not adhered to in this instance.
Lack of Dialysis Emergency Kits for Residents
Penalty
Summary
The facility failed to ensure that a dialysis emergency kit was readily available for two residents who required dialysis services. Resident 85, who was admitted with diagnoses including diabetes mellitus and dependence on renal dialysis, was observed without a dialysis emergency kit at their bedside. The Treatment Nurse confirmed the absence of the kit, which is essential for controlling bleeding at the dialysis access site in an emergency. This oversight placed Resident 85 at risk for excessive bleeding, which could lead to serious harm or death. Similarly, Resident 44, admitted with end-stage renal disease and dependence on renal dialysis, also lacked a dialysis emergency kit at their bedside. The Registered Nurse Supervisor confirmed the absence of the kit, emphasizing its importance in managing potential bleeding emergencies. The Director of Nursing later acknowledged that the facility did not have policies and procedures in place to ensure the availability of dialysis emergency kits at the bedside, further contributing to the deficiency.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information reflecting the actual hours worked by both licensed and unlicensed nursing staff responsible for resident care per shift. This deficiency was observed during a recertification survey, where it was noted that the staffing information was not posted in a prominent location for two out of four days. Specifically, the staffing information was found inside the North Nurses' Station, and no information was posted in the South Nurse's Station, making it inaccessible to residents, family, and visitors. During interviews, the Director of Staff Development (DSD) admitted to projecting the actual hours worked by nursing staff and was unaware that the information needed to be posted in a location accessible to residents, family, and visitors. The facility's policy and procedures indicated that staffing information should be posted in a prominent location within two hours of the beginning of each shift. The DSD acknowledged that the current posting location inside the North Nurses' Station was not accessible to those outside the station, which could mislead residents and visitors about the staffing levels available for resident care.
Failure to Implement GDR and Limit PRN Orders for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that five residents on psychotropic drugs were free from unnecessary medication. Specifically, the facility did not attempt a Gradual Dose Reduction (GDR) for two residents and did not limit PRN orders for psychotropic medications to 14 days for three residents. These practices had the potential to lead to inappropriate use of psychotropic drugs, affecting the residents' physical, emotional, and psychosocial well-being. Resident 25, admitted under hospice care for end-stage Alzheimer's disease, was prescribed Seroquel and Haloperidol for agitation. Despite only two episodes of agitation being recorded, there was no documented attempt at GDR for Seroquel, nor was there an evaluation for the continued use of Haloperidol beyond 14 days. The Director of Nursing acknowledged the oversight in following up on the discontinuation of these medications. Resident 47, with severe cognitive impairment, had been on a consistent dose of Seroquel since 2022 without any documented GDR attempts, despite minimal behavior incidents. Additionally, Residents 13, 41, and 77 had PRN orders for antianxiety medications that exceeded the 14-day limit without reevaluation by a physician. The facility's policy required PRN orders for antipsychotic medications to be reassessed every 14 days, which was not adhered to in these cases.
Inadequate Infection Control and Water Safety Management
Penalty
Summary
The facility failed to establish a comprehensive infection prevention and control program, specifically in monitoring and managing water safety to prevent the growth of Legionella and other waterborne pathogens. During interviews, the Administrator admitted that the facility did not monitor water management, as they believed there were no stagnant waters, and acknowledged the absence of preventative measures for Legionella. The Infection Preventionist Nurse confirmed that although the facility had a policy for Legionella surveillance and detection, there were no implementations for such surveillance. The facility's policy indicated that all pneumonia cases diagnosed 48 hours after admission should be investigated for Legionnaire's disease, but this was not being followed. Additionally, the facility failed to adhere to Enhanced Barrier Precautions (EBP) for a resident with a Foley catheter, which increased the risk of infection. The resident's care plan required continuous monitoring, signage on the door, and proper PPE usage to prevent cross-infection. However, observations revealed that there was no EBP signage posted outside the resident's room, nor was there a PPE cart provided. Interviews with the Registered Nurse Supervisor and the Infection Preventionist Nurse confirmed that these precautions were necessary and should have been in place to prevent the spread of infection.
Failure to Include Advance Directive in Resident's Medical Chart
Penalty
Summary
The facility failed to adhere to its policy on Advance Directives (AD) by not ensuring a current copy of a resident's AD was included in the medical chart. This deficiency was identified for one of the sampled residents, who was admitted with diagnoses including a urinary tract infection, hyperlipidemia, and constipation. The resident was alert and oriented, with intact cognitive abilities, and had both an AD and a Physician Orders for Life Sustaining Treatment (POLST) form. However, during a review, it was found that the AD was not present in the resident's medical chart, only the POLST was available. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed that the facility's policy required the AD to be prominently displayed in the medical record. The SSD acknowledged that the ADPA form was not specific enough to indicate whether the resident had an AD or a POLST, which could lead to the resident's wishes not being respected if the AD differed from the POLST. The DON confirmed that the absence of the AD in the medical chart posed a risk of not honoring the resident's wishes. The facility's policy stated that information about the existence of an AD should be prominently displayed in the medical record, which was not followed in this case.
Privacy Breach During Bed Bath
Penalty
Summary
The facility failed to maintain privacy for Resident 28 during a bed bath, which was observed by surveyors. Resident 28, who was admitted with diagnoses of dementia and epilepsy, had moderately impaired cognition and required assistance with personal care. During the bed bath, Certified Nursing Assistant 6 (CNA 6) did not adequately cover Resident 28's body, leaving the resident exposed while washing different areas. The privacy curtain was left open, and another CNA entered the room, further compromising Resident 28's privacy. The facility's policy and procedure for giving a bed bath were not followed by CNA 6. The policy required washing one part of the body at a time, covering each area after washing, and changing the bath water as necessary. However, CNA 6 used the same water for washing different parts of Resident 28's body and did not cover the resident appropriately, leading to exposure. This lack of adherence to the facility's procedures resulted in a deficiency related to maintaining the privacy and dignity of Resident 28.
Failure to Implement Translation Services for LEP Resident
Penalty
Summary
The facility failed to implement its policy and procedure on Translation and Interpretation services for a resident with limited English proficiency (LEP). The resident, who was admitted with a wedge compression fracture, unspecified hearing loss, and a history of falling, had the capacity to understand and make decisions. The resident's preferred language was Chinese, as indicated in the Minimum Data Set. However, during an observation, the resident called out in Spanish, and the Licensed Vocational Nurse (LVN) communicated by pointing to body parts, which did not ensure the resident understood the purpose of the medication being administered. There was no communication board at the bedside to facilitate communication in a language the resident could understand. The Activities Director (AD) confirmed that the facility had communication boards in Spanish, Arabic, Filipino, and Mandarin, which were supposed to be at the bedside for residents who could not communicate in English. The AD stated that without these boards, residents' needs would not be met. The facility's policy indicated that individuals with LEP should have meaningful access to information and services, and that their needs and questions should be accurately communicated to the staff. The failure to provide appropriate communication tools for the resident with LEP had the potential to result in unmet needs.
Failure to Respond to Call Light in a Timely Manner
Penalty
Summary
The facility failed to respond to a call light and provide timely assistance to a resident, identified as Resident 289, who required help with activities of daily living. Resident 289 was admitted with a history of falling and a wedge compression fracture of the first lumbar vertebra. The resident's care plan indicated the need for assistance, and the Minimum Data Set assessment confirmed the requirement for maximal assistance with sitting on the side of the bed and moderate assistance with sit-to-stand and toilet transfers. Despite these needs, the resident's call light was observed to be on for 31 minutes without a response, during which time the resident expressed the need for help to use the restroom. Interviews with facility staff, including a Certified Nursing Assistant and a Registered Nurse Supervisor, revealed that the facility's policy required call lights to be answered within five to six minutes. Both staff members acknowledged that a 30-minute wait was unacceptable and posed a risk of the resident attempting to get up unassisted, potentially leading to a fall or injury. The facility's policy and procedure on call light response were not adhered to, resulting in a deficiency in providing timely care and assistance to Resident 289.
Failure to Address Resident's Positioning Preference Delays Wound Healing
Penalty
Summary
The facility failed to develop and implement interventions to address a resident's positioning preference, which potentially delayed wound healing. The resident, who had a non-healing wound on the left lateral and medial ankle, preferred to lie on her left side. Despite this preference, the facility did not create care plan interventions to address the resident's positioning, which was crucial given the location of the wound. Observations over several days showed the resident consistently lying on her left side, even when repositioned by staff, indicating a lack of effective intervention to prevent pressure on the wound. Interviews with staff, including a CNA and a wound care nurse, confirmed the resident's preference to lie on her left side and the need for repositioning to aid wound healing. However, the care plans reviewed did not include specific interventions to manage the resident's positioning preference, despite the presence of an open wound with visible metal. The facility's policy on wound care required reviewing the care plan for special needs, but this was not adequately addressed for the resident's situation.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development of pressure ulcers for Resident 16, who was observed to have redness at the base of the left lateral toe and the right big toe. Resident 16, who was admitted with diagnoses including benign neoplasm of the endocrine pancreas and infection due to internal orthopedic prosthetic devices, was noted to have moderate cognitive impairment and required extensive assistance with bed mobility. Despite having a care plan that included a pressure-reducing device for the bed and a turning and repositioning program, observations over several days showed that Resident 16 consistently remained on her left side, which was her preferred position. Interviews with staff, including a CNA and the Wound Care Nurse, confirmed that Resident 16 preferred lying on her left side, and attempts to reposition her were often unsuccessful. The facility's policy on the prevention of pressure ulcers emphasized the need for frequent repositioning, especially for residents with cognitive impairments. However, the staff did not effectively implement these preventive measures, as Resident 16 was observed to remain in the same position for extended periods, leading to the development of redness on her toes, indicating potential pressure ulcer formation.
Failure to Provide Restorative Services as Ordered
Penalty
Summary
The facility failed to adhere to its policy and procedure on Restorative Services by not providing restorative services in accordance with the Medical Doctor's order for a resident. The resident, who was admitted with spinal stenosis and bilateral artificial knee joints, required assistance with activities of daily living and had an order for a Restorative Nursing Assistant program for ambulation five days a week. However, the Treatment Administration Record for May 2024 showed blank spaces on several dates, indicating that the ambulation program was not performed as ordered. Interviews with the Restorative Nursing Aide and the Director of Nursing confirmed that the blank spaces in the Treatment Administration Record meant the treatment was not completed. The Director of Nursing acknowledged that not performing the RNA exercises as per the MD's order placed the resident at risk for contractures or a decline in ADL function. The facility's policy on Restorative Services required staff to assist residents with prescribed physical therapy exercises, which was not followed in this case.
Failure to Secure Foley Catheter as Per Care Plan
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a Foley catheter, as indicated in the resident's care plan. Resident 189, who was admitted with diagnoses including a urinary tract infection and benign prostatic hyperplasia, was observed with a Foley catheter that was not secured to the inside of the thigh as required by the care plan. This lack of proper securing of the catheter was noted during an observation in the resident's room. Interviews with nursing staff confirmed that the Foley catheter should have been secured to prevent accidental pulling, which could cause trauma to the resident. The facility's policy and procedure for catheter care also indicated that the catheter should be secured with a leg strap to reduce friction and movement at the insertion site. The failure to adhere to these guidelines and the resident's care plan had the potential to result in catheter-related complications for Resident 189.
Failure to Monitor Fluid Intake for Resident on Restriction
Penalty
Summary
The facility failed to accurately monitor the fluid intake of a resident, identified as Resident 30, who was on a physician-ordered fluid restriction. Resident 30 was admitted with diagnoses including hypertension, anemia, and atrial fibrillation, and had a care plan that required fluid intake monitoring due to hyponatremia. Despite these requirements, the facility's records showed that the resident's fluid intake consistently exceeded the prescribed limits over several days, with nursing and dietary records documenting intakes far above the allowed 1200 cc per day. Interviews with facility staff revealed a lack of awareness and proper measurement practices regarding the resident's fluid restriction. Certified Nurse Assistant 6 was unaware of any residents on fluid restriction, and Licensed Vocational Nurse 4 admitted to estimating fluid intake without using a measuring cup. The facility's policy required coordination between dietary and nursing staff to ensure compliance with fluid restrictions, but this was not effectively implemented, leading to potential complications for the resident due to electrolyte imbalance.
Failure to Properly Administer Enteric Coated Medication
Penalty
Summary
Licensed Vocational Nurse 2 (LVN 2) failed to ensure that enteric coated Aspirin was not crushed during medication administration for Resident 7. The resident, who was admitted to the facility with conditions including gastroesophageal reflux disease, dementia, and atherosclerotic heart disease, was observed to have their medications crushed and mixed with applesauce by LVN 2. This included the enteric coated Aspirin, which is designed to prevent degradation by gastric acids and should not be crushed. During an interview, LVN 2 admitted to always crushing Resident 7's medications due to the resident's inability to swallow whole pills, but was unaware that enteric coated Aspirin should not be crushed. The Director of Nursing confirmed that delayed release or enteric coated medications should not be crushed and that an alternative form should be sought with a physician's order. The facility's policy indicated that a list of medications not to be crushed should be available for reference, but this was not adhered to in this instance.
Medication Storage Temperature Non-Compliance
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the storage of medications, specifically in maintaining the required temperature in the Medication Refrigerator (MR) in Medication Storage Room 1 (MSR 1). During an observation and interview, it was noted that the MR thermometer displayed a temperature of 62 degrees Fahrenheit, which was outside the required range of 36 to 46 degrees Fahrenheit. Licensed Vocational Nurse 4 (LVN 4) confirmed the temperature reading and expressed uncertainty about whether the thermometer was functioning correctly. Upon rechecking, the temperature was found to be 56 degrees Fahrenheit, still outside the acceptable range. LVN 4 acknowledged that a malfunctioning thermometer could potentially compromise the effectiveness or stability of the medications stored in the MR. Further interviews with Registered Nurse Supervisor 2 (RN Sup 2) reinforced the importance of maintaining the MR temperature within the specified range to prevent the risk of affecting medication potency and bacterial growth. The facility's policy and procedure on Storage of Medication clearly stated that the MR must have working thermometers, and licensed nurses are required to log the temperature twice daily to ensure compliance. The failure to maintain the MR at the required temperature could lead to medications becoming unstable and ineffective, posing a risk to patient safety.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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