Valley View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Delano, California.
- Location
- 729 Browning Road, Delano, California 93215
- CMS Provider Number
- 555053
- Inspections on file
- 45
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Valley View Care Center during CMS and state inspections, most recent first.
Surveyors identified that an annual performance evaluation was not completed for one of five sampled CNAs, contrary to facility policy requiring at least yearly reviews of each employee’s job performance. Review of the CNA’s personnel file with the DSD showed the last evaluation was documented more than a year prior, and the DSD acknowledged that no subsequent evaluation had been done. The facility’s policy also required that completed evaluations be forwarded to HR for inclusion in the personnel record, but no current evaluation was present, creating the potential for the CNA to provide care that may not meet residents’ needs.
The facility failed to follow its Drug Diversion policy to ensure secure storage, accurate documentation, and accountability of hydrocodone for three residents. An LVN discovered that a hydrocodone bubble-pack and its inventory sheet were missing for a resident, prompting a broader review that revealed additional missing hydrocodone bubble-packs and inventory sheets for two other residents, as well as multiple additional missing packs for the first resident. Because the inventory sheets were missing and no copies were kept when narcotics were delivered, narcotic counts appeared correct and the losses went undetected, resulting in the diversion of a total of 164 hydrocodone tablets.
A resident with major depressive disorder and other medical conditions was started on Depakote 250 mg twice daily for mixed mania and bipolar with aggressive behaviors, but the facility did not conduct an IDT review prior to initiating the psychotropic medication. The MARs showed the resident received Depakote consistently while behavior monitoring specific to the medication was not initiated until several days after treatment began. The Social Services Director confirmed that required behavioral monitoring and IDT involvement, as outlined in the facility’s psychotropic medication and Psychotropic Drug Committee policies, were not implemented when the medication was started.
The facility did not follow its Background Investigations policy when an LVN was hired and allowed to work without a completed reference check in the employee file. During review, the Administrator confirmed that the reference check should have been completed before the LVN began working, as the policy requires job reference checks, drug screenings, licensure verifications, and criminal conviction record checks for all applicants. This lapse was identified as having the potential to expose residents to abuse, neglect, and mistreatment.
A CNA was observed mimicking and laughing at a resident with severe cognitive impairment who was calling out for help in Spanish. The CNA's actions, witnessed by staff and confirmed in facility records, were deemed unprofessional and failed to uphold the facility's policy on resident dignity and respect.
A resident's care plan was found to be incomplete, missing measurable timetables and specific actions to address all identified needs. Review of records and observations confirmed that the care plan did not fully document or plan for the resident's care requirements.
A resident with a history of physical aggression and multiple psychiatric diagnoses was not properly monitored or separated from others in the dining area as required by their care plan. This lapse allowed the resident to physically touch another resident on the jaw with a closed fist. Staff interviews confirmed knowledge of the care plan but acknowledged it was not followed at the time of the incident.
A resident with epilepsy and capsular glaucoma reported increased sunlight in her room due to a new untinted sliding glass door. Despite voicing her complaint to the maintenance worker, no action was taken, and the facility failed to document or address the grievance as per their policy.
A resident with a history of falls and mobility issues fell and injured their foot when two CNAs failed to use a Hoyer lift as required by the care plan. Instead, they attempted to transfer the resident using a bath towel, resulting in a fall and a possible fracture. The CNAs were aware of the care plan but did not follow it, leading to the incident.
The facility failed to educate staff on Legionnaires' Disease, lacked proper infection control surveillance, and did not adhere to CDC guidelines. Observations showed improper storage and cleaning of equipment, and inconsistent hand hygiene practices by staff, potentially leading to the transmission of infectious diseases.
The facility did not follow its policy on Resident Rights for three residents who were unaware of how to contact the Ombudsman. During interviews, the residents stated they did not know the Ombudsman contact information or where related posters were located. The Activities Director confirmed that this information was not provided during group meetings, contrary to the facility's policy.
The facility failed to document Advance Directives (AD) for 12 residents, including new admissions, as required by their policy. During interviews and record reviews, it was confirmed that these residents did not have AD acknowledgments in their medical records, which could lead to their healthcare wishes not being honored in emergencies.
The facility failed to provide the Binding Arbitration Agreement in a language and form that residents and their representatives could understand. The agreements were only available in English, despite some residents speaking other languages. The Business Office Manager did not ensure full understanding of the agreement's terms, and some residents signed without comprehension. The facility's policy required explanations in a language understood by the resident or representative, which was not followed.
The facility failed to ensure proper informed consent for antipsychotic medications for three residents. Physician statements of risks, benefits, and alternatives were missing from the PMEC forms, and physician signatures were absent. Verbal consent was obtained via telephone but was not validated by two licensed personnel as required. This deficiency was identified during interviews and record reviews, highlighting a breach in the facility's informed consent policy.
A facility failed to ensure a resident was trained in self-administration of suction, potentially risking respiratory complications. The resident, who was alert and able to communicate, had a suction machine with a container of tan frothy liquid at his bedside. An LVN was seen replacing the container, but no documentation of training or assessment for the resident's ability to use the machine was found. The resident reported using the machine up to five times daily, and a policy for its use was not provided.
A facility failed to notify the OSLTCO about a resident's transfer to an acute care facility, as required by regulations. The resident, who was hospitalized multiple times due to low hemoglobin and high potassium levels, did not have their transfers reported to the Ombudsman. The facility's policy mandates timely notification to the resident, their representative, and the Ombudsman, but this was not adhered to for transfers in October and November.
A facility failed to complete a baseline care plan (BCP) for a resident with COPD, Diabetes Mellitus, and Congestive Heart Failure within 48 hours of admission. The MDS Coordinator confirmed that the BCP was not documented, and the resident did not receive a summary, contrary to the facility's policy requiring a BCP and summary within 48 hours.
The facility failed to update comprehensive care plans for three residents, leading to potential unmet care needs. A resident with foot issues had no care plan for foot care, another had eating difficulties without a documented plan, and a third with diabetes lacked a care plan for diabetes management. Observations and interviews confirmed these deficiencies.
A facility failed to notify the attending physician of a psychiatrist's recommendation to increase Trazodone for a resident with depression. The resident was observed in poor hygiene and expressed feelings of depression, impacting his daily activities. The facility's policy requires notifying the physician of significant changes, but this was not done, as confirmed by the MDS Coordinator.
The facility failed to provide adequate foot care and documentation for two residents. One resident had significant foot issues, including foot drop and discolored, swollen toes, without proper assessment or physician notification. A podiatry recommendation for a vascular surgeon referral was also ignored. Another resident had edematous feet and long toenails, with a doctor's recommendation for a podiatry referral not documented or acted upon. The facility did not adhere to its policies on documentation and podiatry services.
A resident with neuromuscular dysfunction of the bladder had an indwelling urinary catheter without a physician's order for catheter care, leading to frequent urinary tract infections. The DON could not provide documentation for catheter care orders, and the last catheter replacement was months ago, contrary to the facility's policy requiring detailed physician's orders.
A resident was observed with a nasal cannula attached to an empty oxygen tank while sitting in her wheelchair on the facility's patio. She was pursed lip breathing, indicating potential respiratory distress. An LVN confirmed the tank was empty and admitted to not checking it before taking the resident outside. The resident had a physician's order for continuous oxygen at 2 to 4 L/Min for shortness of breath, and the facility's policy requires oxygen to be administered under a physician's order.
The facility failed to provide required annual training on recognizing and reporting elder and dependent adult abuse, neglect, and exploitation to a significant number of CNAs, LVNs, and RNs. This deficiency was identified during a review of training records, which showed no documented training for many staff members, as confirmed by the DSD. The facility's policy requires annual education, but the lack of compliance could lead to unreported abuse incidents.
The facility failed to provide necessary follow-up for medically-related social services for two residents, resulting in delays in dental and vision care. One resident required dentures and vision follow-up, but there was no documentation of referrals or follow-up. Another resident had dental x-rays taken, but no subsequent follow-up was documented. The facility did not adhere to its policy for providing and documenting these services.
A facility failed to follow its medication storage policy when a medication cup containing Bio-freeze gel was left unattended at a resident's bedside. LVN 6 identified the substance and was unaware of how long it had been there. The facility's policy requires medications to be stored in locked compartments and under direct observation during medication passes.
A resident did not receive the prescribed meal items necessary for their nutritional needs, as indicated on their meal ticket. The meal tray was missing several items, including ice cream and fortified soup, which were confirmed by the LVN and CDM. Additionally, the resident struggled to cut meat into bite-sized pieces, and there was no documentation or notification to the physician regarding this issue, contrary to the facility's policy.
A facility failed to provide a necessary assistive feeding device for a resident, as observed during a meal service. The resident was served on a regular ceramic plate instead of the required divided plate, as indicated on their Meal Ticket. The Certified Dietary Manager confirmed the oversight, which was contrary to the facility's policy on providing adaptive equipment for meal consumption.
The facility failed to maintain an effective antibiotic stewardship program. A resident was treated with Fluconazole without proper evaluation or follow-up by the IP, who lacked documentation of diagnostic tests and did not consult the physician. Additionally, the facility did not conduct required Antibiotic Stewardship Meetings, and the IP failed to provide necessary education to the nursing staff, as outlined in the facility's policy.
The facility failed to obtain informed consent for flu vaccines for three residents and did not provide risk and benefit explanations for two residents who refused the vaccine. Additionally, documentation for a resident's vaccine administration was incomplete, lacking essential details such as lot number and site of injection.
The facility failed to obtain COVID-19 vaccination consent for two residents and did not inform two others of the risks and benefits of vaccine refusal. The Infection Preventionist acknowledged the absence of consent forms and lack of documentation, while the Nurse Consultant confirmed the absence of a policy on vaccination consents.
A resident's oxygen tank was found unsecured in their room, posing a potential health hazard. An LVN observed the tank standing without proper support, contrary to the facility's policy requiring oxygen cylinders to be secured in racks. A Respiratory Therapist confirmed the incident was unacceptable and dangerous, highlighting a lapse in adherence to safety protocols.
A resident's personal funds, initially totaling $2,600, were not properly accounted for while stored in a nurse's medication cart, resulting in only $50 remaining without documentation of withdrawals. The facility's policies on fund management and abuse prevention were not followed, leading to potential emotional distress for the resident.
The facility failed to administer physician-ordered treatments for several residents, including medicated ointments and wound dressings, as confirmed by the DON. The staff did not document these treatments, suggesting they were not performed, which is against the facility's wound treatment management policy.
A resident recovering from surgery was subjected to undignified treatment by a CNA, who made an inappropriate comment about starving children and failed to deliver the resident's breakfast tray on time. The resident, who was cognitively intact, felt demeaned and confused by these actions, which violated the facility's policy on maintaining resident dignity.
A resident with anxiety disorder and paraplegia reported that staff placed a towel in her rectal area, causing her to scream. An LVN responded by closing the resident's door during these episodes, without attempting appropriate interventions or informing the DON. The facility's policy on resident dignity was not upheld, as the situation was not investigated or care planned.
A resident with anxiety disorder and paraplegia made multiple allegations of staff inserting chili and towels into her rectum, but staff failed to report these incidents as required by facility policy. Despite the resident's intact cognition and need for maximum assistance, staff, including CNAs and LVNs, did not follow procedures for reporting abuse. The facility's Administrator was aware of the allegations but did not report them due to the resident's history of false claims, leading to a deficiency.
A resident with Parkinson's disease, convulsions, and schizophrenia experienced ten falls due to inaccurate fall risk assessments by nursing staff. The DON acknowledged that the assessments were not conducted correctly, leading to inappropriate interventions. The facility's policy required accurate assessments to ensure safety, but this was not achieved, resulting in a deficiency.
Failure to Complete Required Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to ensure an annual performance evaluation was up to date for one of five sampled CNAs, as required by facility policy. During an interview and concurrent record review with the Director of Staff Development (DSD), the CNA’s personnel file, initiated on 8/10/20, showed that the last documented annual performance review was completed on 12/28/24, and the DSD confirmed that no annual performance evaluation had been conducted for 2025. Review of the facility’s undated Performance Evaluations policy indicated that each employee’s job performance shall be reviewed and evaluated at least annually, and that completed evaluations are to be sent by the director or supervisor to the HR Director for placement in the employee’s personnel record. The surveyor determined that this lapse had the potential to result in the CNA providing care that does not meet residents’ needs. No additional resident-specific clinical information or medical history was provided in the report related to this deficiency.
Failure to Prevent and Detect Diversion of Hydrocodone for Multiple Residents
Penalty
Summary
The facility failed to implement its Drug Diversion policy and procedure to ensure secure storage, accurate documentation, proper administration, monitoring, and accountability of narcotic controlled substances for three residents. During an interview and record review with the Administrator, it was determined that one nurse discovered a missing hydrocodone 10/325 mg bubble-pack containing 28 pills for one resident, along with the corresponding inventory sheet, when starting an evening shift. The Administrator stated that the nurse knew this hydrocodone bubble-pack should have been present because he had administered from it two days earlier. Following this discovery, the facility expanded its search and found that two additional residents each had a missing hydrocodone 5/325 mg bubble-pack of 28 pills, also with missing inventory sheets, and that three more hydrocodone 10/325 mg bubble-packs for the first resident were missing with their inventory sheets. The Administrator reported that the missing inventory sheets were the main reason the hydrocodone losses were not detected for the three residents, because the narcotic count appeared to be correct in the absence of those records. The Administrator also stated that copies of the inventory sheets for resident narcotics are not taken when medications are delivered, which contributed to the inability to track when the narcotics were received and subsequently went missing. A facility five-day report indicated that a total of 164 hydrocodone pills were diverted. The facility’s written Drug Diversion policy states that the facility maintains zero tolerance for narcotic drug diversion and requires secure storage, accurate documentation, and immediate documentation of all narcotic administrations in the MAR and Controlled Substance Record, but these requirements were not effectively carried out in practice for the affected residents.
Failure to Obtain IDT Review and Behavior Monitoring for Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedure on the use of psychotropic medications for a resident who was prescribed Depakote. The resident was admitted with diagnoses including major depressive disorder, history of falling, shortness of breath, and muscle weakness. A physician order dated 1/29/26 directed that the resident start Depakote 250 mg by mouth twice daily for mixed mania and bipolar due to aggressive behaviors, and the medication was initiated that evening and continued thereafter. Record review of the Medication Administration Records (MARs) for January and February showed that the resident received Depakote 250 mg twice daily from 1/29/26 through the end of February. The January MAR indicated the resident started Depakote on the evening of 1/29/26 and continued at 8 a.m. and 6 p.m., but there was no behavior monitoring documented for Depakote use during that time. The February MAR showed that behavior monitoring related to Depakote was not initiated until 2/11/26, despite the resident having been on the medication since 1/29/26. During an interview and concurrent electronic medical record review with the Social Services Director, it was confirmed that the resident was started on Depakote 250 mg twice daily without an Interdisciplinary Team (IDT) meeting having been conducted to determine the appropriateness of initiating this psychotropic medication. The Social Services Director stated that staff were supposed to monitor the resident’s behaviors while on Depakote to determine if the medication and dosage were appropriate, but this was not done initially. The facility’s policies on Use of Psychotropic Medications and the Psychotropic Drug Committee require adequate indications for use, evaluation of nonpharmacological interventions, IDT involvement, and documentation of the resident’s response to psychotropic medications, which were not implemented for this resident at the time Depakote was started and during the initial period of its administration.
Failure to Complete Required Background Reference Check for LVN
Penalty
Summary
The facility failed to follow its Background Investigations policy by allowing a licensed vocational nurse (LVN 2) to work without completion of a required reference check. During an interview and employee file review with the Administrator, it was found that LVN 2’s reference check section in the employee file was not completed, despite LVN 2 having been employed at the facility since 2/13/24. The Administrator acknowledged that, per facility policy and procedure, reference checks should have been completed prior to the nurse beginning work. The written Background Investigations policy stated that job reference checks, drug screenings, licensure verifications, and criminal conviction record checks are to be conducted on all applicants for employment, and that applicants who do not consent to such investigations will not be considered for positions requiring them. The survey finding noted that this failure had the potential to expose residents to abuse, neglect, and mistreatment.
CNA Mocked Resident's Cry for Help, Violating Dignity Standards
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed engaging in unprofessional and inappropriate behavior toward a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 6. The resident, who has a known behavior pattern of yelling and screaming for help in Spanish, was calling out 'ayudame' when the CNA approached, got down to the resident's level, and repeatedly mimicked the resident's cries for help while laughing. This interaction was witnessed by other staff members, including the Director of Staff Development (DSD) and the Administrator, both of whom described the CNA's actions as unprofessional and inappropriate. Facility records, including a 5-day report and policy on promoting and maintaining resident dignity, confirmed that the CNA's behavior did not align with the facility's standards for treating residents with respect and dignity. The policy specifically requires staff to speak respectfully to residents and to maintain or enhance each resident's quality of life by recognizing their individuality. The incident was documented as a failure to provide dignity and respect, with the potential to cause emotional distress to the resident involved.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the resident's records, which showed that the care plan did not comprehensively cover all identified needs, nor did it include clear, measurable goals or interventions.
Failure to Implement Care Plan Intervention for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to implement a care plan intervention for a resident with a history of physical aggression towards others. The care plan, established due to previous incidents, required staff to monitor the resident and keep him separated from other residents in the dining area. Despite this intervention being documented and known to staff, the resident was able to physically touch another resident on the jaw with a closed fist during a meal. Multiple staff interviews confirmed awareness of the care plan requirement, but acknowledged that the intervention was not followed at the time of the incident. The resident involved had diagnoses including schizoaffective disorder, bipolar disorder, and adjustment disorder, and had previously exhibited physically aggressive behavior. The other resident involved had developmental and mental health diagnoses. The incident was witnessed by a visitor, reported to staff, and resulted in the residents being separated, with no injuries noted. Facility policy required comprehensive care plans to be implemented and for staff to be notified of their responsibilities, but this was not carried out in this instance, leading to the deficiency.
Failure to Address Resident Grievance Regarding Increased Sunlight
Penalty
Summary
The facility failed to implement its policy and procedure on grievances for a resident who had a diagnosis of epilepsy and capsular glaucoma. The resident's admission record indicated that bright light could negatively affect her condition. The resident reported that a new sliding glass door installed in her room lacked tint, which increased the amount of sunlight entering her room and bothered her eyes. She voiced her complaint to the facility's maintenance worker, but no action was taken to address her concern. The maintenance worker confirmed that the resident's sliding glass door was replaced and that the resident had complained about the increased light. He stated that he communicated the resident's concerns to the facility's leadership during daily morning meetings. However, there was no documentation of the complaint or any response from the facility. The Administrator in Training and the Social Services Director were aware of the complaint but were unsure of the process to address grievances and had not completed a grievance form for the resident's complaint. The facility's policy on grievances requires prompt efforts to resolve complaints, including acknowledgment and active resolution efforts. The policy also mandates that the Grievance Official oversee the grievance process, issue written decisions, and maintain confidentiality. Despite these requirements, the facility did not follow its policy, as there was no documentation or written decision regarding the resident's grievance, and the grievance process was not properly executed.
Failure to Use Hoyer Lift Results in Resident Fall and Injury
Penalty
Summary
The facility failed to prevent an avoidable fall for a resident when two Certified Nursing Assistants (CNAs) did not follow the care plan that required the use of a Hoyer lift for transfers. Instead, the CNAs attempted to transfer the resident using a bath towel, which resulted in the resident falling and experiencing pain in the left foot. The resident was later found to have a possible fracture in the left great toe. The resident, who had a history of repeated falls, difficulty walking, and required assistance with personal care, was dependent on staff for transfers. The care plan specifically indicated the use of a Hoyer lift with two staff members for any transfers. However, during the transfer, the CNAs lost control of the bath towel, causing the resident to fall to the floor. The resident reported pain in the left foot following the incident, and subsequent medical evaluations confirmed a nondisplaced fracture. Interviews with the CNAs revealed that they were aware of the requirement to use the Hoyer lift but chose to use a bath towel instead, a method they were not trained to use. The facility's policies emphasized the importance of following the care plan and using mechanical lifts for safe resident handling and transfers. The failure to adhere to these policies and the care plan led to the resident's fall and injury.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to provide education to staff on the prevention and recognition of Legionnaires' Disease, as evidenced by the Infection Preventionist's inability to provide documentation of such education. The Water Management Program indicated that nursing staff should be educated about Legionnaires' Disease to aid in early identification, but the Infection Preventionist admitted to not having conducted this education. This lack of education could hinder early identification and response to potential cases of Legionnaires' Disease among residents. Infection control surveillance activities were inadequately conducted, as the Infection Preventionist could not provide documentation of these activities. Although competencies on hand hygiene and the donning and doffing of PPE were available, there was no evidence of ongoing surveillance for healthcare-associated infections or other significant infections. This lack of documentation and surveillance could impede the facility's ability to track and trend infections effectively, potentially leading to unaddressed infection risks. The facility also failed to adhere to infection prevention and control practices as per CDC guidelines. Observations revealed multiple lapses, including the improper storage and cleaning of resident-care equipment, such as razors, wheelchair footrests, and a Hoyer Lift. Additionally, hand hygiene practices were not consistently followed by staff, as evidenced by instances where staff did not perform hand hygiene after removing gloves or before assisting residents with meals. These failures in maintaining cleanliness and proper hygiene practices could contribute to the transmission of infectious diseases within the facility.
Failure to Inform Residents of Ombudsman Contact Information
Penalty
Summary
The facility failed to adhere to its policy and procedure titled Resident Rights for three of nine sampled residents, specifically Residents 19, 28, and 43. These residents were unaware of how to contact the Ombudsman, an independent advocate for residents in long-term care facilities. During a group interview, all three residents stated they did not know how to contact the Ombudsman office and were unaware of the location of Ombudsman posters. Additionally, Resident 43 mentioned that the contact information for the Ombudsman was not discussed during group meetings. The Activities Director confirmed that she does not provide information on how to contact the Ombudsman during group meetings, which is contrary to the facility's policy that requires residents to receive notice of contact information for advocacy organizations, including the Ombudsman program.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that 12 out of 32 sampled residents had an Advance Directive (AD) documented in their medical records. An AD is a legal document that provides instructions for medical care and only goes into effect if the individual is unable to make decisions for themselves. During interviews and record reviews, it was found that several residents, including new admissions, did not have an AD acknowledgment in their medical records. The Social Services Director (SSD) and Medical Record Director (MRD) confirmed the absence of these documents during their reviews. The facility's policy and procedure, titled 'Residents' Right Regarding Treatment and Advance Directives,' requires that upon admission, the facility determines if a resident has executed an AD and provides information about the right to refuse treatment and formulate an AD. However, the facility did not adhere to this policy, as evidenced by the lack of AD documentation for the residents reviewed. This failure could potentially lead to responsible parties and medical professionals not honoring residents' healthcare wishes in emergency situations.
Failure to Provide Arbitration Agreement in Understandable Language
Penalty
Summary
The facility failed to ensure that the Binding Arbitration Agreement (BAA) was provided in a form and language that six sampled residents and/or their representatives could understand. The Business Office Manager (BOM) admitted that the arbitration agreements were only available in English, despite some residents speaking other languages such as Tagalog, an Indian language, and Spanish. The BOM also acknowledged that she did not explain the full content of the agreement, only the concept of arbitration, and did not ensure that residents or their representatives fully understood the terms and conditions. Additionally, the BOM did not have a process to evaluate the residents' understanding of the agreement, nor could she articulate how disputes would be handled or where arbitration would take place. Specific instances included Resident 34, who had a Brief Interview of Mental Status (BIMS) score indicating severe cognitive impairment, yet signed the BAA herself without a clear understanding. Resident 3's BAA was signed by a niece who did not have legal power of attorney, and the agreement was not provided in a language understood by the resident. Resident 25, with an intact cognitive status, and Resident 149 both expressed that they did not fully understand the agreement they signed during admission. The facility's policy required that the arbitration agreement be explained in a language and manner that the resident or representative understands, which was not adhered to in these cases.
Failure to Obtain Proper Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that physicians provided informed consent for the use of antipsychotic medications for three sampled residents. This deficiency was identified during interviews and record reviews, where it was found that the necessary physician statements of risks, benefits, and alternatives were missing from the Psychoactive Medication Evaluation and Consent (PMEC) forms. Additionally, the forms lacked physician signatures, indicating that the physicians did not provide the informed consent for the prescribed medications. For Resident 1, the facility's records showed that verbal consent for medications such as Lorazepam, Trazodone, and Abilify was obtained from the resident's sister via telephone. However, the verbal consent process was not properly followed, as it required validation by two licensed personnel, but only one Licensed Vocational Nurse (LVN) validated the consent. Similar issues were found with Resident 40 and Resident 149, where the PMEC forms for medications like Zolpidem and Trazodone also lacked the necessary physician statements and signatures. The facility's policy and procedure for informed consent, dated 12/14/17, clearly stated that the healthcare practitioner ordering psychotherapeutic medication is responsible for obtaining informed consent and providing documentation of the risks and benefits. The policy also required telephone verification of informed consent with two witnesses, which was not adhered to in these cases. This failure had the potential to prevent residents from receiving accurate information about their medications and understanding the associated risks, benefits, and alternatives.
Failure to Train Resident in Self-Administration of Suction
Penalty
Summary
The facility failed to ensure that a resident was trained in self-administration of suction, which had the potential to place the resident at risk for respiratory infection and/or complications. During an observation, a suction machine with a plastic container containing tan frothy liquid was noted on the bedside table of the resident, who appeared alert and was able to verbalize his needs. A Licensed Vocational Nurse (LVN) was observed replacing the plastic container on the suction machine. Upon review of the resident's medical record, there was no documentation of an Interdisciplinary Team (IDT) training or assessment for the resident's ability to suction himself. The resident reported using the suction machine up to five times a day. A facility policy and procedure for the use of the suction machine was requested but not provided.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman (OSLTCO) about the transfer of a resident to an acute care facility, as required by regulations. During an interview and record review with the Director of Nursing (DON) and Medical Records Director (MRD), it was found that Resident 25 had been hospitalized multiple times due to medical conditions such as low hemoglobin and high potassium levels. However, there was no documentation indicating that the OSLTCO was informed of these transfers, which is a necessary step to ensure the resident's rights and protections are upheld. The facility's policy and procedure on transfers and discharges require that notices be provided to the resident, their representative, and the Ombudsman in a timely manner, especially in cases of emergency transfers. Despite this, the MRD admitted to not sending the required notifications for the months of October and November 2024. The DON was also unable to provide evidence that the OSLTCO was notified of Resident 25's transfers during this period, highlighting a lapse in compliance with federal regulations and the facility's own policies.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure that a baseline care plan (BCP) was completed and provided to a resident within 48 hours of admission. This deficiency was identified for a resident who was admitted with multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, and Congestive Heart Failure, and who required assistance with personal care and had difficulty walking. During a review of the resident's admission record, it was found that the BCP was not completed, and a summary was not provided to the resident within the required timeframe. During an interview and record review with the Minimum Data Set (MDS) Coordinator, it was confirmed that there was no documentation of a completed BCP for the resident, and the resident did not receive a summary of the BCP. The facility's policy and procedure for baseline care plans required that a BCP be developed within 48 hours of admission and that a written summary be provided to the resident, with a signature obtained to verify receipt. However, these steps were not followed, leading to the deficiency.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to update and develop comprehensive person-centered care plans for three residents, leading to potential unmet care needs. For Resident 3, observations revealed foot drop, dry and scaly skin, and fungal-like toenail conditions, with no updated care plan addressing these issues. The CNA noted potential pain during repositioning, but the MDS Coordinator confirmed the absence of a documented care plan for foot care. Resident 1 experienced difficulty cutting and chewing meat, consuming only 25% of their meal, yet there was no nursing documentation or updated care plan addressing these eating difficulties. Similarly, Resident 31, who has Type 2 Diabetes Mellitus, lacked a documented care plan for diabetes management, despite having a high A1C level and requiring monitoring for signs of hypo- and hyperglycemia. The resident reported that nursing staff did not inquire about specific diabetes-related symptoms, and the LVN confirmed the absence of a care plan for diabetes management.
Failure to Notify Physician of Psychiatric Recommendation
Penalty
Summary
The facility failed to notify the attending physician of a psychiatrist's recommendation to increase the dosage of Trazodone for a resident experiencing depression. This oversight was identified during observations and interviews with the resident, who appeared unkempt and expressed feelings of depression, impacting his willingness to engage in daily activities and self-care. The resident was observed wearing the same clothes over consecutive days, with signs of poor hygiene and physical neglect, such as oily hair, edematous and dry skin, and long, unkempt toenails. The psychiatric evaluation conducted recommended an increase in Trazodone to address the resident's depression, but there was no documentation indicating that the attending physician was informed of this recommendation. The facility's policy requires that significant changes in a resident's condition be communicated to the physician, but this protocol was not followed. The Minimum Data Set Coordinator confirmed the lack of documentation and communication regarding the psychiatrist's recommendation, highlighting a failure in the facility's process for managing changes in a resident's mental health condition.
Failure to Provide Adequate Foot Care and Documentation
Penalty
Summary
The facility failed to ensure proper foot care for two residents, leading to potential adverse consequences due to delayed treatments. For Resident 3, the facility did not assess and notify the physician about significant foot problems, including foot drop, dry and scaly skin, and discolored, swollen toes with long, thick toenails. Despite observations indicating potential pain, there was no documentation of a nurse's assessment or physician notification. Additionally, a podiatry recommendation for a vascular surgeon referral was not acted upon. Resident 149 also experienced inadequate foot care. During an examination, a medical doctor noted edematous feet due to congestive heart failure, with dry, scaly skin and long, yellowish toenails. The doctor recommended a podiatry referral, but there was no documentation of this recommendation in the progress notes or a physician's order for the referral. The facility's policies on documentation and podiatry services were not followed, as assessments and necessary referrals were not documented or completed. The facility's failure to document and act on the necessary foot care assessments and referrals for these residents indicates a lack of adherence to their own policies and procedures. This oversight in documentation and communication with physicians could lead to delayed treatments and adverse outcomes for the residents involved.
Lack of Physician's Order for Catheter Care
Penalty
Summary
The facility failed to ensure that a physician's order for catheter care was in place for a resident with an indwelling urinary catheter due to neuromuscular dysfunction of the bladder. The resident, who had been using a Foley catheter for three years, reported frequent urinary tract infections. During an observation, the catheter tubing was noted to be cloudy, indicating potential issues with catheter maintenance. Upon review, the Director of Nursing (DON) could not provide documentation of a physician's order for catheter care, including the frequency of catheter changes. The only orders available were for measuring urine intake and output. The last documented catheter replacement occurred when it was dislodged several months prior. The facility's policy requires catheter use to be in accordance with physician's orders, including details on the necessity, size, and change frequency, which were not documented in this case.
Failure to Ensure Full Oxygen Tank for Resident
Penalty
Summary
The facility failed to ensure that Resident 199 had a full portable oxygen tank available for use, which was necessary for her respiratory care. During an observation on the facility's outside patio, Resident 199 was seen sitting in her wheelchair with a nasal cannula attached to an empty oxygen tank. She was observed pursed lip breathing, a technique used to maximize oxygen intake, indicating potential respiratory distress. Licensed Vocational Nurse (LVN) 8 confirmed the oxygen tank was empty and acknowledged the oversight in not checking the tank before taking the resident outside. Resident 199 had a physician's order for continuous oxygen administration at 2 to 4 liters per minute via nasal cannula for shortness of breath. The facility's policy on oxygen administration requires oxygen to be administered under a physician's order, consistent with professional standards of practice.
Failure to Provide Required Annual Abuse Training
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the annual training of staff on recognizing and reporting elder and dependent adult abuse, neglect, and exploitation. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), where it was found that a significant number of Certified Nursing Assistants (CNAs), Licensed Vocational Nurses (LVNs), and Registered Nurses (RNs) had not received the required annual training. Specifically, twenty-seven out of forty-two sampled CNAs, seventeen out of twenty-two sampled LVNs, and seven out of eight sampled RNs lacked documented evidence of having completed the training. The facility's policy, dated 11/29/24, mandates that existing staff receive annual education through planned in-services and as needed. However, the training records reviewed, covering the period from 1/3/24 to 7/23/24, showed no documented training for the listed staff members. The DSD confirmed the absence of additional training documentation, indicating a systemic failure to ensure compliance with the facility's training policy. This lapse had the potential for abuse incidents to go unnoticed and unreported within the facility.
Failure to Provide Follow-Up for Medically-Related Social Services
Penalty
Summary
The facility failed to ensure that two residents received necessary follow-up for medically-related social services, specifically concerning dental and vision care. Resident 40, who had missing teeth and required full mouth dentures, was seen by a dentist three months prior, but there was no follow-up to ensure the dental recommendations were carried out. Additionally, Resident 40 had an order for vision follow-up, but there was no documentation of a referral to an ophthalmologist. The lack of social services follow-up resulted in delays in addressing these needs. Similarly, Resident 25, who had yellowish, decayed, and missing teeth, had dental x-rays taken, but there was no subsequent follow-up documented by social services. The facility's policy and procedure for social services, which mandates the provision and documentation of medically-related social services, was not adhered to, leading to these deficiencies in care for the residents.
Unattended Medication at Bedside
Penalty
Summary
The facility failed to adhere to its medication storage policy when a medication was left unattended at the bedside of a resident. During an observation, a 30 ml plastic medication cup, 3/4 full of a blue gel-like substance, was found on the bedside table of Resident 99. Licensed Vocational Nurse (LVN) 6 identified the substance as Bio-freeze gel, a medication used to treat minor aches and pains of the muscles/joints. LVN 6 was unaware of how long the medication had been left there and noted that it is typically found on the medication treatment cart. Further observations and interviews with Certified Nursing Assistant (CNA) 3 and the Director of Nursing (DON) confirmed that the medication cup should not have been left in the resident's room. The facility's policy and procedure on Medication Storage, dated 11/29/2024, mandates that all drugs and biologicals be stored in locked compartments and under direct observation during medication passes. The unattended medication at the bedside posed a potential risk for residents to inadvertently use it without supervision.
Failure to Provide Prescribed Meal and Assess Resident's Eating Ability
Penalty
Summary
The facility failed to ensure that a resident received the food items as specified on their meal ticket, which was necessary to meet their nutritional requirements. During a meal observation, it was noted that the resident's lunch tray did not include ice cream, fortified soup, a sandwich, or Nutri juice, all of which were indicated on the meal ticket. The Licensed Vocational Nurse confirmed the absence of these items, and the Certified Dietary Manager acknowledged that these items should have been included. The resident's physician's order also specified that ice cream should be provided twice daily with lunch and dinner. Additionally, the facility did not assess the resident's ability to cut meat into bite-sized pieces and feed themselves. During an observation, the resident struggled to cut the meat, and there was no documentation in the nursing progress notes or care plan regarding this difficulty. The Minimum Data Set Coordinator confirmed the lack of documentation and that the physician was not notified about the resident's difficulty in cutting the meat and eating. The facility's policy indicated that menus should be developed in collaboration with a Registered Dietitian and should adhere to the written menu, which was not followed in this case.
Failure to Provide Assistive Feeding Device
Penalty
Summary
The facility failed to provide an assistive feeding device for a resident who required it, potentially impacting the resident's nutritional status. During an observation and interview, it was noted that the resident's lunch tray contained a regular ceramic plate instead of the required divided plate. The Certified Dietary Manager (CDM) acknowledged that the resident should have been served on a divided plate as indicated on the undated Meal Ticket. The facility's policy on Adaptive Equipment-Feeding Devices, dated 2020, specifies that appropriate assistance and adaptive equipment, such as built-up dishes with inner lips and plate guards, should be provided to residents to aid in meal consumption.
Deficiencies in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by several deficiencies. The Infection Preventionist (IP) did not evaluate or follow up on a resident who was treated with an antibiotic for a fungal infection. Specifically, the IP was unable to provide documentation of any diagnostic tests, such as an X-ray or blood work, to validate the resident's diagnosis of a fungal infection. Furthermore, the IP was not aware of the reason for the resident's prescription of Fluconazole and did not consult with the physician regarding the treatment. Additionally, the facility did not conduct an Antibiotic Stewardship Meeting, which should have been led by the Pharmacist, Medical Director, and Director of Nursing. The IP admitted that the pharmacist was not involved in the antibiotic stewardship program, and there was no consultation with the pharmacist. Moreover, the IP failed to provide evidence of antibiotic stewardship education for the nursing staff, which is a requirement according to the facility's policy and procedure. The lack of these critical components in the antibiotic stewardship program had the potential to lead to inappropriate antibiotic treatment for residents.
Failure to Obtain Consent and Document Vaccine Administration
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the administration of influenza vaccines for five residents. Specifically, Residents 10, 8, and 7 were administered the flu vaccine without obtaining informed consent from the residents or their legal representatives. This oversight was identified during interviews and record reviews with the Infection Preventionist (IP), who confirmed the absence of signed consents in the clinical records of these residents. Additionally, Residents 100 and 2 did not receive explanations of the risks and benefits associated with their refusal of the flu vaccine, and there were no declination statements documented for these refusals. Furthermore, the facility did not maintain proper documentation for the administration of the flu vaccine to Resident 7. The Administration Note for Resident 7 lacked critical information such as the lot number, expiration date, the person administering the vaccine, and the site of injection. These documentation lapses were contrary to the facility's policy, which mandates that such details be recorded in the resident's medical file. The failure to document these details accurately could lead to potential issues in tracking the vaccine in case of adverse reactions or recalls.
Failure to Obtain COVID-19 Vaccination Consent and Inform Residents of Risks
Penalty
Summary
The facility failed to complete the COVID-19 vaccination consent forms for four of 31 sampled residents. Resident 10 and Resident 7 received the COVID-19 vaccine without obtaining consent from the residents or their legal representatives. Additionally, Resident 100 and Resident 2 were not informed of the risks and benefits associated with refusing the COVID-19 vaccine. These deficiencies were identified during interviews and record reviews with the Infection Preventionist, who acknowledged the absence of consent forms and the lack of documentation regarding the risks and benefits of vaccine refusal. The Infection Preventionist admitted to not having updated the vaccination records, and the Nurse Consultant confirmed that the facility lacked a policy on the completion of vaccination consents. These failures resulted in the potential for inaccurate medical records and the spread of infectious diseases.
Unsecured Oxygen Tank Poses Risk in LTC Facility
Penalty
Summary
The facility failed to ensure the proper storage of an oxygen tank for a resident, which posed a potential health hazard. During an observation and interview, a Licensed Vocational Nurse (LVN) found an oxygen tank with an attached gauge meter and oxygen tubing standing unsecured on the right side of a resident's bed. The LVN acknowledged that the oxygen tank should have been secured in a rack. A Respiratory Therapist (RT) confirmed that the director of respiratory care was informed after the fact and stated that the unsecured tank was unacceptable and dangerous, posing a risk to both the resident and staff. The facility's policy and procedure on Oxygen Safety, dated 11/29/24, specifies that oxygen cylinders must be properly chained or supported in racks or other fastenings to prevent them from falling, regardless of whether they are connected, unconnected, full, or empty. Additionally, the policy indicates that oxygen cylinders should not be stored with gauges attached, and liquid oxygen base reservoir containers must be secured to prevent tipping over.
Failure to Account for Resident's Personal Funds
Penalty
Summary
The facility failed to ensure the proper accounting of a resident's personal funds, which were kept secured in the nurse's medication cart. The deficiency involved a resident who initially had $2,600 stored in an envelope within the cart, as documented and signed by both the resident and an LVN. Over time, the amount in the envelope decreased without proper documentation or explanation, leaving only $50 when the resident reported the funds missing. The facility's policy required that any removal of funds be documented with the date, amount, and signatures of both the nurse and the resident, which was not adhered to in this case. Interviews with the Director of Nursing and the Administrator revealed that the responsibility for documenting the removal of funds lay with the nurses who had access to the medication cart. However, there was no documentation indicating when or who removed the total of $2,550 from the envelope. The facility's policies on resident personal funds and abuse prevention were not followed, leading to the unaccounted funds and potential emotional distress for the resident.
Failure to Administer Physician-Ordered Treatments
Penalty
Summary
The facility failed to provide physician-ordered treatments for four sampled residents, leading to potential adverse effects on their health. Resident 1 did not receive Mupirocin External Ointment for a skin infection on multiple occasions and missed a Medi-honey Wound/Burn Dressing treatment for a diabetic ulcer. Resident 2 did not receive Santyl External Ointment for a wound on the left shin during several shifts. Resident 3 missed multiple treatments, including antifungal powder, Betadine Solution, barrier cream, Hydrogel External Gel, and zinc oxide ointment for various skin conditions and wounds. Resident 4 did not have the dressing on the left foot kept dry and intact as ordered. The Director of Nursing (DON) confirmed these findings, acknowledging that the staff failed to document the treatments, implying they were not administered. The facility's policy on wound treatment management, dated November 2023, mandates that treatments be provided according to physician orders and documented in the Treatment Administration Record or electronic health record. The lack of documentation and adherence to physician orders represents a significant deficiency in the facility's care practices.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by the actions of a Certified Nursing Assistant (CNA). On one occasion, the CNA told the resident that they were lucky to receive three meals a day because there are starving children in the world. This comment was made after the resident expressed a lack of appetite due to recovering from surgery. The resident, who was cognitively intact with a BIMS score of 14, felt demeaned by the CNA's remark. The following day, the same CNA failed to deliver the resident's breakfast tray while serving other residents in the room, despite having been recently in-serviced on the proper procedure for meal distribution. The resident did not receive their meal until another staff member noticed the oversight and provided the tray. This incident left the resident feeling confused and wondering if they were being punished for the previous day's interaction. The facility's policy on promoting and maintaining resident dignity emphasizes treating residents with respect, which was not upheld in this situation.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by the actions of a Licensed Vocational Nurse (LVN) who repeatedly closed the resident's door during episodes of yelling. The resident, who has a diagnosis of anxiety disorder and paraplegia, reported that staff placed a towel in her rectal area, causing her to scream. The LVN, identified as LVN 2, responded to the resident's yelling by closing the door to her room, which was not an intervention discussed or care planned by facility leadership. The Director of Nursing (DON) was not informed of the resident's behavior, and no appropriate interventions, such as redirection or speaking in a calm manner, were attempted before closing the door. The resident's Minimum Data Set (MDS) indicated intact cognition, and the Progress Notes documented multiple instances of the resident yelling out about alleged incidents involving towels and chili. Despite the resident's repeated claims, LVN 2 continued to close the door without consulting the resident's roommates or neighboring residents. The facility's policy on promoting and maintaining resident dignity emphasizes treating residents with respect and dignity, which was not upheld in this situation. The DON acknowledged that closing the door was not an appropriate response and that the situation should have been investigated with proper interventions implemented.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to adhere to its policy and procedure on reporting allegations of abuse for a resident, resulting in a deficiency. The resident, who has a diagnosis of anxiety disorder and paraplegia, made multiple allegations that staff were inserting chili and towels into her rectum. Despite these serious allegations, staff members, including CNAs and LVNs, did not report the incidents as required by the facility's policy. The resident's Minimum Data Set indicated she had intact cognition and required maximum assistance for personal hygiene, showering, lower body dressing, and toileting. Interviews with various staff members revealed a pattern of inaction regarding the resident's allegations. A CNA admitted to not reporting the allegations because of the resident's history of making similar claims. An LVN, who was aware of the allegations, also failed to report them, citing uncertainty about whether a report had been made. The Social Services Director was informed of verbal aggression by another staff member but could not recall taking any action. Progress notes from May to July documented the resident's repeated claims and instances of blood in her stool, yet these were not reported as abuse allegations. The facility's policy mandates immediate investigation and reporting of all abuse allegations to the Administrator, state agency, and other required agencies within specified timeframes. However, the Administrator, who was aware of the allegations, did not report them due to the resident's history of false claims. This failure to follow established procedures placed the resident and potentially other residents at risk for further abuse.
Inaccurate Fall Risk Assessment Leads to Deficiency
Penalty
Summary
The facility failed to accurately assess a resident for fall risk, which had the potential to prevent appropriate interventions from being implemented. The resident, who had a history of Parkinson's disease, convulsions, schizophrenia, difficulty in walking, and required assistance with personal care, experienced ten fall incidents since the beginning of 2024. Despite these incidents, the fall risk assessments conducted by the nursing staff were inconsistent and inaccurate, leading to inappropriate fall risk scores and interventions. The Director of Nursing (DON) acknowledged that the fall risk evaluations were not conducted correctly, resulting in fluctuating fall risk scores that did not reflect the resident's actual risk. The facility's policy required accurate fall risk assessments to ensure a safe environment and appropriate supervision, but the assessments were not completed correctly, as evidenced by the incorrect answers inputted by the nursing staff. This failure to accurately assess and address the resident's fall risk was a significant deficiency in the facility's care provision.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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