Valley Vista Nursing And Transitional Care Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in North Hollywood, California.
- Location
- 6120 N. Vineland Ave, North Hollywood, California 91606
- CMS Provider Number
- 555132
- Inspections on file
- 94
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Valley Vista Nursing And Transitional Care Llc during CMS and state inspections, most recent first.
A resident admitted with multiple fractures, including sacral, rib, scapular, and vertebral fractures, and prescribed PRN Hydrocodone-Acetaminophen for severe pain did not have these conditions or pain management needs addressed in the comprehensive care plan. The MDS documented moderately impaired cognition and need for moderate assistance with ADLs, yet the care plan omitted interventions for fracture care and pain control. An LVN and the DON acknowledged that the care plan was not comprehensive and did not reflect the resident’s existing conditions as required by facility policy.
A resident with schizoaffective disorder, bipolar disorder, depression, and generalized anxiety disorder, and with documented behavioral issues such as aggression and yelling, was transferred to a GACH on a 5150 psychiatric hold for danger to others and later readmitted. Despite GACH records noting verbal aggression, agitation, labile mood, inability to contract for safety, and suicidality, the resident’s comprehensive care plan was not revised after the hospital stay to address the transfer, the 5150 hold, or the readmission. An LVN confirmed the omission during record review, and the DON acknowledged that the care plan should have been updated with new approaches and interventions, contrary to facility policy requiring care plan revision after significant changes in condition and hospital readmission.
Surveyors found that two residents with multiple fractures and moderately impaired cognition did not receive the prescribed opioid doses for severe pain. Review of MARs showed that on multiple occasions, nursing staff administered lower-dose oxycodone and hydrocodone-acetaminophen regimens that were ordered for moderate pain, even though the residents reported severe pain levels. An LVN acknowledged these were medication errors, and the DON confirmed that staff are required to follow prescriber orders, pain scales, and the facility’s medication administration policy, which mandates verification of the right dose before giving medications.
A resident with COPD, emphysema, and hypertensive heart disease experienced documented SOB over multiple consecutive days, with nursing notes repeatedly recording respiratory complaints and observations but no evidence of physician notification. Despite a care plan directing staff to assess respiratory status and notify the MD as indicated, the change in condition was not communicated until the resident developed severe SOB requiring EMS activation and transfer to an acute care hospital, where low oxygen saturation and several days of worsening symptoms were documented. This failure occurred despite facility policy requiring MD notification for significant changes in condition and for situations necessitating hospital transfer.
Two residents did not receive ordered topical medications and wound care as prescribed. One resident with multiple chronic conditions and moderately impaired cognition had physician orders for daily-shift Nystatin powder to abdominal folds for MASD and Mupirocin 2% ointment to both legs for cellulitis; review of the TAR with an RN showed no licensed staff initials for these treatments on two morning shifts, and the RN confirmed there was no documented evidence they were administered. Another resident with paraplegia and a stage 4 sacral pressure ulcer had detailed daily-shift sacral wound care orders involving Dakin’s solution, collagen, hydrocolloid, and foam dressings; the TAR similarly lacked licensed staff initials for two morning shifts, and the RN stated there was no documentation the treatment was completed. Facility policy required medications, including topical treatments, to be administered as prescribed and recorded on the TAR.
A resident with heart failure, epilepsy, COPD, and moderately impaired cognition, who depended on staff for multiple ADLs, experienced vomiting and an O2 saturation of 76% on room air, leading to transfer to an acute care hospital. Despite this significant change in condition, the resident’s comprehensive care plan was not revised to address the vomiting and desaturation, contrary to facility policy requiring the IDT to review and update care plans after significant changes or hospital stays. An RN confirmed that the care plan was not updated and that it serves as the essential guide for staff monitoring and care.
A resident with a history of liver disease and alcohol dependence left the facility AMA after being placed on a one-on-one sitter, but did not receive discharge instructions or information about the risks and benefits of leaving in their preferred language of Spanish. The AMA form was signed in the presence of two RNs who could not communicate in Spanish, resulting in the resident not being fully informed as required by facility policy.
A resident with a history of aggression physically assaulted another cognitively impaired resident, causing injury and pain. Despite prior documented aggressive incidents, there was no evidence of psychiatric evaluation or consistent monitoring, and required follow-up interventions were lacking. Staff confirmed the abuse and facility policies mandated protection from such incidents.
A resident with a history of alcoholic cirrhosis, malnutrition, and alcohol dependence left the facility AMA after being placed on one-on-one supervision. The resident's preferred language was Spanish, but discharge instructions and the AMA form were only provided in English, and staff present could not translate. As a result, the resident left without fully understanding the risks and benefits of leaving AMA.
A resident with schizoaffective disorder and dementia received PRN Haloperidol without an end date or required 14-day re-evaluation, and staff did not monitor or document behavioral symptoms to justify continued use. This failure did not comply with facility policy for antipsychotic medication management.
A resident was readmitted with a new indwelling catheter, but the care plan was not updated to include goals or interventions for catheter care. The omission was confirmed by an RN during record review and interview, despite facility policy requiring care plan updates after significant changes or readmission. The resident had multiple diagnoses and required maximal assistance with daily activities.
A resident with multiple chronic conditions and severe cognitive impairment experienced a significant change in condition with abnormal vital signs. Facility staff did not assess the resident's blood glucose level at the time, despite policy and professional standards requiring this assessment during such events. The omission was acknowledged by nursing staff and resulted in incomplete evaluation during the resident's acute episode.
A resident with severe cognitive impairment and multiple medical conditions was admitted with a new indwelling catheter, but staff failed to place orders for catheter care or monitoring, and there was no documentation of care or assessment as required by facility policy.
A resident with COPD, acute respiratory failure, and dementia did not receive prescribed continuous oxygen therapy or regular spO2 monitoring as ordered. Staff failed to reconnect the nasal cannula and turn on the oxygen concentrator after care, and documentation for oxygen administration and spO2 checks was missing for several shifts, contrary to facility policy.
Two residents with complex medical needs did not have discharge planning included in their person-centered care plans, despite facility policy and staff acknowledgment that social services are responsible for this process. Both the MDS assessments and interviews with the DON confirmed the absence of discharge planning interventions, which is required by facility policy and the Social Services Director's job description.
A resident with multiple chronic conditions requested transfer closer to family, and the Social Services Director engaged in discussions and outreach to potential facilities. However, there was no documentation in the medical record of these communications or actions, contrary to facility policy requiring all services and care planning activities to be recorded.
A resident with multiple medical conditions and total dependence on staff for care was found to have their call light on the floor and out of reach, contrary to their care plan and facility policy. Staff confirmed the importance of keeping the call light accessible, and facility policy required it to be within reach when the resident is in bed.
A resident with multiple respiratory diagnoses was found with her oxygen nasal cannula inside her mouth instead of her nose, despite a physician's order for continuous oxygen via nasal cannula. Staff interviews confirmed the importance of proper placement and adherence to orders, but the deficiency occurred when the device was not correctly positioned, resulting in the resident not receiving oxygen as prescribed.
A resident with depressive disorder, hypertension, and anxiety disorder was found to be living in a room and restroom that were not clean or homelike, with visible residue, rust, and broken fixtures. Both an LVN and the DON confirmed the lack of cleanliness, which did not meet facility policy for maintaining a sanitary and comfortable environment.
Three residents with various medical conditions and decision-making capacity were not provided with written information about their right to formulate an Advance Directive upon admission. Staff interviews and record reviews confirmed that required documentation and discussions did not occur, and the facility's process for informing residents about ADs was not followed.
The facility failed to obtain informed consent and properly monitor the use of psychotropic medications for several residents, including not documenting behavioral indications, adverse effects, or end dates for PRN orders. Staff did not follow required procedures for consent and ongoing evaluation, and behavior monitoring documentation was missing for multiple months for two residents receiving antipsychotic and antianxiety medications.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided, resulting in regulatory noncompliance.
A resident requiring dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's requirements.
Two residents experienced deficiencies in pharmaceutical services when an LVN failed to administer and accurately document prescribed medications, including amiodarone and famotidine, and did not seek supervisory assistance when confused. Additionally, Epogen was administered to another resident without required hemoglobin monitoring, contrary to physician orders and manufacturer guidelines.
A staff member did not level the scoop when serving egg noodles, resulting in larger portions than specified by the facility's menu and standardized recipe. This affected most residents receiving egg noodles, including those on a consistent carbohydrate (CCHO) diet, and was confirmed by observation, staff interview, and review of facility policies and recipes.
A resident did not receive food prepared in a form that met their individual needs, as the facility did not consistently modify meals to accommodate specific dietary requirements or physical abilities.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, as observed during the survey.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, or serve food according to professional standards, as observed by surveyors.
A gap in a reach-in freezer door led to significant ice buildup, as observed by staff and confirmed through interviews with the Dietary Supervisor and Maintenance Supervisor. Despite awareness of the issue and a temporary fix with a metal plate, the freezer continued to have a gap, and the manufacturer's guidance was not sought. This deficiency affected the safe storage of food for medically compromised residents.
The facility did not maintain sanitary conditions in the kitchen, as flies were observed flying and landing on food preparation surfaces and equipment during trayline and food prep. The Dietary Supervisor confirmed that flies entered when staff opened doors to bring in supplies, and acknowledged the risk of cross-contamination. This failure had the potential to affect most residents receiving food from the kitchen.
Surveyors found that two residents with cognitive and physical impairments had their call lights placed behind their beds and out of reach. CNAs, an RN, and the DON confirmed that the call lights should have been accessible to allow residents to request assistance, in accordance with facility policy.
Two residents did not receive comprehensive care plans addressing their specific needs: one resident with a history of stroke and falls did not have a post-fall care plan developed after an actual fall, and another resident with multiple diagnoses did not have a care plan for bowel and bladder incontinence management or retraining. Staff interviews and record reviews confirmed that required care planning processes and facility policies were not followed.
The facility did not ensure that services provided met professional standards of quality, as evidenced by observations and record reviews showing inconsistent adherence to accepted guidelines.
A CNA was found to lack a CPR certification accredited by the ARC or AHA, contrary to facility policy requiring all CPR team members to hold such credentials. This was confirmed through interviews and record review with the DON and DSD, who acknowledged the oversight during the hiring process and the importance of compliance with the facility's emergency procedures.
A resident with end stage renal disease, COPD, and anemia received Epogen injections for anemia without a physician's order for hemoglobin monitoring. Nursing staff administered the medication on multiple occasions without ensuring hemoglobin levels were checked, contrary to both the manufacturer's guidelines and facility policy, which require regular monitoring to ensure safe administration.
A resident with intact cognitive function and multiple diagnoses was identified as a candidate for a bowel and bladder retraining program, but staff failed to initiate the program as required by facility policy. Interviews with the MDSC and DON confirmed the omission, which was not in line with established procedures for managing incontinence.
A resident with respiratory failure, CHF, and dementia who was dependent on staff for care was found with a nasal cannula disconnected from the oxygen concentrator, despite physician orders for continuous oxygen. Staff confirmed the tubing should always be connected and that monitoring is their responsibility, in line with facility policy.
Annual competency and performance reviews for two CNAs were not completed within the required 12-month period, as confirmed by the DSD and DON through interviews and employee file audits. Facility policy requires these evaluations to ensure staff competency in patient care and job responsibilities, but documentation was missing for both CNAs.
A resident with end stage renal disease and anemia received Epogen injections without weekly monitoring of hemoglobin levels as required by physician orders and manufacturer guidelines. Nursing staff and the DON confirmed that hemoglobin should have been checked prior to each dose, but the medication was administered without this verification, resulting in a deficiency related to unnecessary drug administration.
A medication error rate of 5 percent or greater was found during the survey, showing that the facility did not maintain medication administration errors below the required limit.
A resident with diabetes received subcutaneous insulin injections without proper rotation of injection sites, contrary to physician orders, manufacturer guidelines, and facility policy. Nursing staff and the DON confirmed that injection sites should have been rotated, and the failure to do so was considered a medication error.
Therapeutic diets were not prescribed by the attending physician or properly delegated to a registered or licensed dietitian as allowed by State law, resulting in dietary orders lacking appropriate authorization.
Staff failed to keep a resident's indwelling urinary catheter drainage bag off the floor, despite facility policy and staff knowledge that this practice increases infection risk. Additionally, food items were found stored in the clean linen closet with residents' clothing and linens, contrary to facility procedures requiring sanitary storage. Both deficiencies were confirmed by staff and supported by facility policy reviews.
Rooms designated for multiple residents were found to be less than 80 square feet per resident, and single resident rooms were less than 100 square feet, as required by regulations.
The facility did not ensure that daily nurse staffing information was accurately posted, as required by policy. Staff confirmed that the posted information was outdated and should have reflected the current day's staffing. This resulted in inaccurate staffing data being available to residents, visitors, and staff.
Two residents did not receive or have documented physician-ordered wound care treatments, and one resident with diabetes did not have required provider notification for multiple elevated blood sugar readings. Nursing staff confirmed the lack of documentation and communication, which was not in accordance with facility policy and physician orders.
A resident with COPD, anxiety disorder, schizophrenia, and impaired cognitive functioning was admitted and readmitted, but the facility did not complete a baseline care plan within 48 hours as required. An LVN confirmed that neither the baseline nor the comprehensive care plan was updated after readmission, contrary to facility policy.
Two residents with cognitive impairments were involved in a physical altercation in the smoking patio, where one resident was choked and fell, resulting in pain and emotional distress. The incident occurred without staff supervision, and witnesses reported that no staff were present or immediately available, which was contrary to facility policy requiring supervision to prevent abuse.
A resident with hypertension and COPD, assessed as capable of self-administering inhaler medications, did not have a care plan developed or implemented to address this physician-ordered intervention. Despite facility policy requiring care plans for self-administration, the omission was confirmed during record review and interview with the DON.
A resident with multiple chronic conditions and a recent bladder infection did not receive cephalexin 500 mg as ordered, with several doses administered late or outside the facility's required time window. Staff interviews and record reviews confirmed the medication was not given within the prescribed timeframe on multiple occasions, contrary to physician orders and facility policy.
Failure to Care Plan for Fractures and Pain Management
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for a resident admitted with multiple fractures and pain management needs. The resident was admitted with diagnoses including a nondisplaced zone II sacral fracture, multiple left rib fractures, a displaced fracture of the scapular body, and other fractures of the fourth and fifth vertebrae. The History and Physical documented that the resident had capacity to understand and make decisions, while the MDS assessment showed moderately impaired cognitive functioning and a need for moderate assistance with oral hygiene, toileting hygiene, toilet transfers, showers, and personal hygiene. A physician’s order dated shortly after admission prescribed Hydrocodone-Acetaminophen 5-325 mg, two tablets by mouth every four hours as needed for severe pain. During an interview and concurrent record review, an LVN confirmed that the resident’s care plan did not address the resident’s fractures or pain management, despite these documented conditions and orders. The LVN stated that the care plan is the guide for staff interventions and that failure to include pain management and fracture care could lead to staff mistakes and delayed care. The DON also stated that the care plan should have addressed all existing conditions and acknowledged that the resident’s care plan was not comprehensive. Review of the facility’s policy on comprehensive, person-centered care plans showed that it required development and implementation of a care plan with measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs, derived from a thorough assessment and reflecting recognized standards of practice, which was not done for this resident’s fractures and pain management.
Failure to Revise Behavioral Care Plan After Psychiatric Hospitalization and Readmission
Penalty
Summary
The facility failed to revise a resident’s comprehensive care plan following a significant change in condition and readmission from a general acute care hospital (GACH) on a 5150 psychiatric hold. The resident, originally admitted on 12/18/2024 and later readmitted, had diagnoses including schizoaffective disorder, bipolar disorder, depression, and generalized anxiety disorder. A Minimum Data Set dated 3/16/2026 showed moderately impaired cognitive functioning, with the resident independent in eating, oral hygiene, toileting hygiene, and ambulation. A care plan created on 3/11/2026 identified behavior problems such as aggression, hitting staff, kicking objects, yelling, and cursing. On 3/16/2026 at 2:01 p.m., a progress note documented that the resident was transferred to GACH for psychiatric evaluation on a 5150 hold due to aggressive behavior toward staff and refusal of medications. GACH records from 3/16/2026 indicated the resident was admitted on a hold for danger to others and being gravely disabled, with documented verbal aggression, irritability, agitation, labile mood, inability to contract for safety, and endorsement of suicidality. During a concurrent interview and record review on 4/14/2026, an LVN confirmed that the resident’s care plan did not address the transfer to GACH on a 5150 hold or the subsequent readmission. In an interview on 4/15/2026, the DON stated that the care plan should have been revised after readmission to provide new approaches and interventions to prevent recurrence of previous problems and to manage the resident’s behavior. The facility’s policy on comprehensive person-centered care plans, last reviewed on 2/26/2026, required that care plans be revised when there is a significant change in condition and when a resident is readmitted from a hospital stay, which did not occur in this case.
Failure to Administer Correct Opioid Doses for Severe Pain
Penalty
Summary
Surveyors identified a deficiency in medication administration related to opioid pain management for two residents. For Resident 1, who was admitted with multiple fractures including a displaced cervical vertebra and nasal bone fracture and had moderately impaired cognition, the physician ordered oxycodone 10 mg by mouth every four hours as needed for severe pain (7–10/10) and oxycodone 5 mg every four hours as needed for moderate pain (4–6/10). Review of the March MAR showed that on three separate dates, at evening administration times, nursing staff documented administering only 5 mg of oxycodone when Resident 1 reported severe pain at a level of 8/10. During interview, LVN 1 acknowledged that the 10 mg dose should have been given for severe pain and that giving the 5 mg dose instead was a medication error with the potential for unrelieved pain. For Resident 3, who was admitted with multiple traumatic fractures including sacral, rib, scapular, and vertebral fractures and also had moderately impaired cognition, the physician ordered hydrocodone-acetaminophen 5-325 mg, one tablet every six hours as needed for moderate pain (4–6/10), and two tablets every four hours as needed for severe pain (7–10/10), with a maximum daily acetaminophen limit. Review of the April MAR showed that on two separate mornings, nursing staff documented administering only one 5-325 mg tablet when Resident 3 reported severe pain at levels of 8/10 and 10/10. LVN 1 confirmed that the single-tablet dose was ordered for moderate pain and that two tablets should have been administered for severe pain, identifying these as medication errors. The DON stated that licensed staff are expected to follow prescriber orders, the pain scale, and residents’ reported pain levels when administering pain medications. The facility’s “Administering Medications” policy, last reviewed in February, directed that medications be administered safely, timely, and as prescribed, and required the individual administering medications to check the label three times to verify the right resident, medication, dosage, time, and route before administration. Despite these requirements, the documented administrations for both residents did not match the ordered dosages for the reported severe pain levels, resulting in the cited deficiency for failure to ensure residents were free from significant medication errors.
Failure to Notify Physician of Resident’s Ongoing Shortness of Breath
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s primary physician of a significant change in respiratory status over several days. The resident was admitted with COPD, emphysema, and hypertensive heart disease and had moderate cognitive impairment, requiring partial to moderate assistance with activities of daily living. The resident’s care plan for impaired gas exchange and ineffective airway clearance related to COPD included interventions to assess respiratory function, monitor for respiratory changes, and notify the physician as indicated. Progress notes documented that, beginning on 2/7/2026, the resident experienced shortness of breath, initially while lying flat, and then on subsequent days continued to report and exhibit shortness of breath. These respiratory symptoms were documented on 2/7, 2/8, 2/9, 2/10, and 2/11, but there was no documentation or evidence that the resident’s physician was notified of this ongoing change in condition. Facility nursing staff, including an LVN and an RN, later acknowledged that the resident’s shortness of breath had been present since 2/7/2026 and that the physician should have been notified during that period. On 2/12/2026 at 3:26 a.m., an SBAR was completed identifying a COPD exacerbation with severe shortness of breath, and an order was entered at 4:34 a.m. to transfer the resident to an acute care hospital. Emergency medical services documented that the resident reported having shortness of breath for the past five days without help and was found to have an oxygen saturation of 82% on room air when picked up from the facility. The hospital emergency department record indicated the resident presented with progressively worsening shortness of breath over six days. The facility’s own policy on change in a resident’s condition required nursing staff to notify the attending physician when there was a significant change in the resident’s physical condition or a need to transfer the resident to a hospital, which did not occur during the days when the resident’s shortness of breath was repeatedly documented.
Failure to Administer and Document Ordered Topical Treatments and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and professional standards of practice for two residents. For one resident with depression, cirrhosis, heart failure, and COPD, the admission record showed the resident was readmitted in January 2026 and had moderately impaired cognition, with dependence on staff for personal hygiene, toileting hygiene, and lower body dressing. Physician orders included daily-shift topical Nystatin powder to abdominal folds for MASD starting 1/28/2026, and Mupirocin 2% ointment to both legs for cellulitis starting 1/29/2026. Review of this resident’s February 2026 Treatment Administration Record (TAR) with an RN on 2/9/2026 showed that on 2/6/2026 and 2/7/2026 at the 7 a.m. administration time, there were no licensed staff initials in the TAR boxes for the ordered Mupirocin ointment treatments to the left and right legs, and no licensed staff initials for the ordered Nystatin powder to the abdominal folds. The RN stated there was no documented evidence that these treatments were administered as ordered on those dates and times and acknowledged that failure to administer the treatments as ordered had the potential to negatively affect the resident’s care and potentially cause wound deterioration, infection, or delay of wound healing. For a second resident admitted with paraplegia, a stage 4 sacral pressure ulcer, and sacral osteomyelitis, the H&P indicated intact decision-making capacity, and the care plan for pressure ulcers directed staff to provide wound care per treatment orders. Physician orders dated 1/23/2026 specified a multi-step daily-shift sacral/coccyx stage 4 pressure ulcer treatment, including cleansing with Dakin’s solution, application of a collagen dressing cut to wound shape, application of a hydrocolloid dressing, and coverage with abdominal pads and Mepilex foam. Review of this resident’s February 2026 TAR with the RN on 2/9/2026 showed that on 2/6/2026 and 2/7/2026 at the 7 a.m. administration time, there were no licensed staff initials documenting completion of the ordered sacral pressure ulcer treatment. The RN stated there was no documented evidence the treatment was done and that failure to administer the treatment as ordered had the potential to cause complications such as infection and deterioration of the pressure ulcer. The facility’s medication administration policy, revised 1/2026, stated that medications are to be administered safely, timely, and as prescribed, and that topical medications used in treatments are to be recorded on the TAR.
Failure to Update Care Plan After Resident Desaturation and Vomiting Episode
Penalty
Summary
The facility failed to revise a comprehensive care plan for a resident after a significant change in condition involving desaturation and vomiting. The resident was admitted with diagnoses of heart failure, epilepsy, and COPD, and had moderately impaired cognitive functioning, requiring staff assistance for toileting hygiene, toilet transfers, showers, and lower body dressing. On review of the resident’s MDS and admission records, these needs and conditions were documented. The facility’s policy required that the comprehensive, person-centered care plan, which includes measurable objectives and timetables to meet physical, psychological, and functional needs, be reviewed and updated when there is a significant change in condition or when a resident is readmitted from a hospital stay. On a specific date, an SBAR Communication Form documented that the resident experienced an episode of vomiting and an oxygen saturation of 76% on room air, and was transferred to a general acute care hospital for further evaluation. During an interview and concurrent record review, an RN confirmed that the resident’s care plan had not been updated to address the episode of vomiting and desaturation. The RN stated that the care plan is an essential guide for staff to provide monitoring to ensure the resident’s condition does not deteriorate and acknowledged that the failure to update the care plan had the potential to delay care and monitoring for the resident.
Failure to Provide Discharge Instructions in Resident's Preferred Language
Penalty
Summary
The facility failed to provide a resident with discharge instructions in the resident's preferred language of Spanish when the resident left the facility Against Medical Advice (AMA). The resident, who had a history of alcoholic cirrhosis with ascites, protein calorie malnutrition, and alcohol dependence, was sometimes able to understand and be understood by others, with Spanish documented as the preferred language. On the day of the incident, the resident expressed a desire to leave after being placed on a one-on-one sitter following an alleged physical abuse incident with another resident. The resident signed an AMA form, which was witnessed by two RNs, neither of whom could speak or translate Spanish. The review of facility records and interviews confirmed that the AMA form and related discharge instructions were not provided in Spanish, and the resident did not receive information about the risks and benefits of leaving AMA in a language he understood. Facility policies require that residents be informed of their rights and responsibilities and be supported in exercising those rights, including being informed in a manner they can understand. The failure to provide instructions in the resident's primary language resulted in the resident not being fully informed to make an appropriate decision regarding leaving the facility AMA.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident physically assaulted another in the hallway. On the morning of the incident, one resident, who had a documented history of verbal and physical aggression, stood up from his wheelchair, grabbed another resident, pinned them against a door, struck their head against the door, and punched them in the face. This resulted in the victim sustaining redness and pain to the left eye, with a pain rating of three out of ten. The incident was witnessed by both a CNA and an LVN, who confirmed the aggressive actions and the use of racial slurs during the altercation. The resident who committed the abuse had a care plan in place for aggression, which included monitoring behavior every shift. However, records revealed multiple prior incidents of aggressive behavior, including several change in condition (COC) events related to aggression in the months leading up to the incident. Despite these documented behaviors, there was no evidence of a psychiatric evaluation or consistent 72-hour monitoring following previous aggressive episodes. Additionally, progress notes did not indicate social services visits after aggressive incidents, suggesting a lack of follow-up and intervention. The victim of the abuse had severe cognitive impairment and a history of encephalopathy, major depressive disorder, and generalized anxiety disorder. The facility's own policies required protection of residents from abuse by anyone, including other residents. Interviews with staff and review of facility policies confirmed that the actions constituted both physical and verbal abuse, and that the facility failed to ensure the safety and well-being of the residents involved.
Failure to Provide Discharge Instructions in Resident's Preferred Language
Penalty
Summary
The facility failed to provide a resident with discharge instructions in their preferred language, Spanish, when the resident chose to leave the facility against medical advice (AMA). The resident, who had a history of alcoholic cirrhosis with ascites, protein calorie malnutrition, and alcohol dependence, was admitted with ongoing needs for long-term care. The Minimum Data Set indicated that the resident's preferred language was Spanish and that communication abilities were sometimes limited. On the day of discharge, the resident expressed a desire to leave after being placed on one-on-one supervision following an alleged incident of physical abuse with another resident. The resident informed staff of plans to go to a hotel, though no specific destination was provided. The resident had an active physician order allowing passes out of the facility for up to four hours. When the resident signed the AMA form, both registered nurses present were unable to communicate in Spanish or provide a translated version of the discharge instructions. Facility policies required that residents be informed of their rights and responsibilities and that discharge planning should address individual needs and preferences, including language. Despite these policies, the facility did not ensure the resident received information about the risks and benefits of leaving AMA in a language the resident could fully understand, resulting in the resident leaving without adequate comprehension of the implications.
Failure to Re-Evaluate PRN Psychotropic Medication and Monitor Behavioral Symptoms
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medication and chemical restraints for one resident by not providing ongoing re-evaluation of the need for PRN Haloperidol. The order for Haloperidol, prescribed for schizoaffective disorder, did not include an end date as required, and the medication was not limited to a 14-day period before re-evaluation by a physician. Additionally, there was no documented monitoring of the resident's behavioral manifestations related to schizoaffective disorder to determine the continued need for the medication. The resident involved had diagnoses including COPD, schizoaffective disorder, and unspecified dementia, with severely impaired cognitive functioning and required maximal assistance with daily activities. The facility's own policy required that antipsychotic medications be prescribed at the lowest possible dosage for the shortest period, with PRN orders not to be renewed beyond 14 days without physician evaluation and documentation. These requirements were not followed, as confirmed by staff interviews and record reviews.
Failure to Update Care Plan for Resident with New Indwelling Catheter
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident who was readmitted with a new indwelling catheter. Upon review, it was found that the care plan did not reflect the presence of the catheter or include goals and interventions necessary for its care. The resident had a history of chronic obstructive pulmonary disease, acute respiratory failure, and unspecified dementia, and required maximal assistance with activities of daily living. The Minimum Data Set indicated severely impaired cognitive functioning, and the resident was unable to make medical decisions independently. During an interview and record review, a registered nurse confirmed that the care plan was not updated upon the resident's readmission, despite the facility's policy requiring care plan revisions after significant changes in condition or readmission from a hospital stay. The lack of an updated care plan meant that staff did not have documented guidance to monitor or address the resident's catheter care, which was necessary to meet the resident's physical and functional needs as outlined in the facility's policy.
Failure to Assess Blood Glucose During Change in Condition
Penalty
Summary
Facility staff failed to assess a resident's blood glucose level during a significant change in condition, despite the presence of abnormal vital signs including low blood pressure, elevated heart rate, increased respiratory rate, low oxygen saturation, and a mild fever. The last recorded blood glucose measurement for the resident was from a week prior to the incident. The resident had a history of chronic obstructive pulmonary disease, acute respiratory failure, and unspecified dementia, with severely impaired cognitive functioning and a need for maximal assistance with daily activities. During the change in condition, the facility's policy required staff to gather all relevant and pertinent information, including blood glucose levels, before notifying a healthcare provider. However, the staff did not obtain a current blood glucose reading at the time of the event. This omission was acknowledged by the registered nurse, who stated that assessing blood glucose is necessary during such events to rule out related complications. The failure to follow professional standards and facility policy resulted in the resident not receiving appropriate assessment and care during a critical change in condition.
Failure to Provide and Document Indwelling Catheter Care and Monitoring
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received proper care and monitoring. Upon admission, the resident had a new indwelling catheter, but staff did not place an order for catheter care or monitoring. Record review confirmed there was no documentation of catheter care or monitoring, and staff interviews revealed that the omission was recognized by both an LVN and an RN. The staff acknowledged that they did not monitor the resident for signs and symptoms of catheter complications, nor did they track intake and output as required. The resident in question had multiple diagnoses, including COPD, acute respiratory failure, and severe cognitive impairment, and required maximal assistance with activities of daily living. Facility policy required observation for catheter complications and documentation of catheter care, including assessment data and urine characteristics. However, these procedures were not followed, and there was no record of catheter care being provided or monitored for this resident.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Facility staff failed to provide respiratory care consistent with professional standards for a resident with chronic obstructive pulmonary disease (COPD), acute respiratory failure, and dementia. The resident required continuous oxygen therapy via nasal cannula at a prescribed flow rate, as well as regular monitoring of peripheral oxygen saturation (spO2) every shift, per physician orders. The care plan also specified returning the resident to their usual oxygen delivery method after meals and administering medications as ordered. During an observation, the resident was found lying in bed with the nasal cannula disconnected and wrapped around the oxygen concentrator, which was turned off. A Licensed Vocational Nurse (LVN) confirmed that the resident was not connected to oxygen and stated that staff should have ensured the oxygen was properly administered after providing care. A Registered Nurse (RN) also acknowledged that staff failed to administer oxygen as ordered, which could result in low oxygen levels and respiratory decline for the resident. Record review revealed that the Medication Administration Record (MAR) lacked staff initials for several shifts, indicating that both oxygen administration and spO2 monitoring were not documented as completed on multiple occasions. Facility policies required staff to check oxygen equipment for proper function and to administer medications, including oxygen, as prescribed and in a timely manner. These actions and omissions led to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Develop and Implement Discharge Planning in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing discharge planning for two residents. For one resident admitted with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and atrial fibrillation, the Minimum Data Set (MDS) indicated substantial assistance was needed for activities of daily living. Despite the Social Services Director stating that discharge planning begins at admission and involves identifying the resident's discharge preferences and necessary resources, a review of the resident's care plan revealed no focus, goal, or intervention related to discharge planning. The Director of Nursing confirmed the absence of discharge planning in the care plan and acknowledged its importance for ensuring a safe and organized discharge process. Similarly, another resident admitted with seizures, hypertension, and depression, and assessed as requiring varying levels of assistance with daily activities, also lacked a care plan addressing discharge planning. The resident's MDS and medical history indicated the capacity to make decisions, yet the care plan did not include any discharge planning components. The Director of Nursing again confirmed that social services are responsible for this aspect of care planning and that its omission could lead to disorganized and stressful discharges. A review of the facility's policies and procedures confirmed that comprehensive, person-centered care plans with measurable objectives and timetables are required for each resident, and that social services staff are responsible for transitions of care, including discharge planning. The job description for the Social Services Director also specified responsibilities for discharge-planning services, such as referrals, follow-up arrangements, and post-discharge care plans. Despite these documented requirements, the facility did not ensure that discharge planning was included in the care plans for the two residents reviewed.
Failure to Document Social Services Discharge Planning Communications
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting the communications and actions taken by social services regarding the resident's discharge planning. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, and major depressive disorder, expressed a desire to be transferred to a location closer to family. The resident reported that discussions about discharge planning with facility staff had occurred weeks prior, and was open to various locations near her desired area. During interviews and record reviews, the Social Services Director confirmed ongoing communication with contacts at potential receiving facilities and discussions with the resident about discharge options. However, there was no documentation in the resident's medical record reflecting these communications or actions. The Director of Nursing also confirmed the absence of any progress notes or records of discharge planning discussions in the electronic medical record. This lack of documentation was not in accordance with the facility's own policies and procedures, which require all services and progress toward care plan goals to be documented.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
The facility failed to ensure that the call light for one resident was accessible and within reach, as required by the resident's care plan and facility policy. The resident had significant medical conditions, including lumbar spondylosis, neuropathy, and respiratory failure, and was dependent on staff for activities such as eating, toileting, personal hygiene, and dressing. The care plan specifically identified the resident as being at risk for falls and required that the call light be kept within reach to allow the resident to request assistance as needed. During an observation, the call light was found on the floor behind the resident's bed, out of reach. Staff interviews confirmed that the call light should be accessible to the resident at all times, and the facility's policy required the call light to be within reach when the resident is in bed. The deficiency was identified through direct observation, staff interviews, and review of the resident's records and facility policies.
Failure to Ensure Proper Placement of Oxygen Nasal Cannula
Penalty
Summary
A deficiency occurred when a resident with diagnoses of congestive heart failure, pleural effusion, and respiratory failure, who was dependent on staff for all activities of daily living, was observed with her oxygen nasal cannula improperly placed inside her mouth while she was sleeping. The resident's care plan required continuous oxygen via nasal cannula, and the physician's order specified oxygen at 2 liters per minute for shortness of breath, with the option to increase up to 5 liters if necessary. During the observation, a CNA acknowledged the importance of proper nasal cannula placement and stated that if it was found out of place, the charge nurse should be notified to address the issue. Further interviews with nursing staff and the DON confirmed that professional standards of practice require checking the placement of the nasal cannula during routine room checks and that the facility's policy specifies the nasal cannula should be placed approximately one-half inch into the resident's nose. The staff confirmed that the doctor's order for oxygen must be followed as written. The failure to ensure the nasal cannula was properly placed in the resident's nose resulted in the resident not receiving oxygen as prescribed.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and homelike environment for one resident by not ensuring the cleanliness of the resident's room and restroom. Observations revealed black residue on the floor and window frame, white residue at the bottom of the window, a dark red coating on the soap dispenser, and a broken metal door upon entering the restroom. The soap dispenser was found to be rusty, and the metal door frame at the bottom of the bathroom door was separating from the door. Additionally, the window and the edge of the sliding door were noted to be dirty and dusty. These findings were confirmed by both a Licensed Vocational Nurse and the Director of Nursing, who acknowledged the room was not clean or homelike. The resident involved had diagnoses of depressive disorder, hypertension, and anxiety disorder, and was assessed as having intact cognitive functioning with a need for moderate assistance in personal hygiene and dressing. Facility policy required a clean, sanitary, and orderly environment, with regular cleaning of housekeeping surfaces and prompt cleaning of visibly soiled areas. The failure to adhere to these standards resulted in the resident not being provided with a clean and homelike environment, as required by facility policy.
Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to ensure that three residents were provided with written information regarding their right to formulate an Advance Directive (AD) upon admission, as required by facility policy and federal regulations. For each of the three residents reviewed, there was no documented evidence that the AD was discussed or that the AD Acknowledgment form was completed. Interviews with the Social Services Director (SSD) and nursing staff confirmed that the process for providing and documenting this information was not followed for these residents. One resident with diagnoses including end stage renal disease, diabetes, dementia, and sepsis was admitted and re-admitted to the facility. The resident was assessed as able to understand and make decisions, but the Social Service History and Initial Assessment Form was incomplete, and there was no documentation that the AD was discussed or that written information was provided. The SSD and nursing staff confirmed that the required AD Acknowledgment form was not completed, and the facility process was not followed. A second resident with hemiplegia, hemiparesis following a stroke, and anxiety disorder, and a third resident with anxiety disorder, bipolar disorder, neuropathy, and psychosis, were both found to have the capacity to understand and make decisions. However, neither had documentation in their records that the AD was discussed or that written information was provided. The SSD and RN confirmed that the AD Acknowledgment forms were not completed for these residents, and that the facility's process for informing residents about their rights regarding ADs was not followed.
Failure to Obtain Consent and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications and chemical restraints, as evidenced by multiple deficiencies in the administration, monitoring, and documentation of such medications for three residents. For one resident with a history of hemiplegia, hemiparesis, depression, and anxiety, the facility did not obtain informed consent prior to administering certain psychotropic medications, specifically diazepam and duloxetine. The resident reported not being informed about the medications being administered, and staff interviews confirmed that the required consent process was not followed, contrary to facility policy and procedure. Additionally, the facility did not provide ongoing re-evaluation of the need for psychotropic medications for this resident, as there was no documented monitoring for measurable behaviors or adverse effects related to bupropion, diazepam, or duloxetine. Orders for PRN diazepam lacked specific, measurable behavioral manifestations and did not include an end date, both of which are required by facility policy to ensure appropriate use and regular reassessment of high-risk medications. Staff interviews confirmed that these omissions could result in the administration of unnecessary medications and potential harm to the resident. For another resident with dementia and anxiety disorder, the facility failed to monitor for measurable behaviors and adverse effects of Risperdal for a specified period and did not complete required behavior summary side effect documentation for several months for both Risperdal and Klonopin. The lack of behavior monitoring and documentation was acknowledged by staff, who stated that such monitoring is necessary to evaluate medication effectiveness and to support gradual dose reduction. These failures were in direct violation of the facility's policies regarding psychotropic medication use, monitoring, and resident rights.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and with resident agreement, as well as deficiencies in the ongoing care and management of residents with feeding tubes.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report excerpt.
Failure to Administer and Document Medications as Ordered and Monitor Lab Values Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer prescribed medications to a resident as ordered by the physician. Specifically, the LVN did not administer amiodarone and famotidine during a scheduled medication pass, despite both medications being ordered for the resident. The LVN incorrectly stated that amiodarone had already been given by the night shift and discarded the medication, while famotidine was not administered because it was not found in the medication cart. The LVN then documented in the medication administration record (MAR) that both medications had been given, even though they were not. The LVN admitted to being confused and acknowledged that the MAR was not accurate, and also failed to seek assistance from a supervisor when unsure about the medication administration process. The resident involved had multiple complex medical conditions, including metabolic encephalopathy, dysphagia, hypertensive heart disease with heart failure, anxiety disorder, depression, a cardiac pacemaker, and a gastrostomy tube. The resident was dependent on staff for all activities of daily living and required medications to be administered via the G-tube. The failure to administer and accurately document the prescribed medications was observed during a medication pass and confirmed through interviews and record reviews. Facility policy required medications to be administered as ordered and documented accurately, with any omissions or errors to be properly recorded and reported. A second deficiency was identified involving another resident who was prescribed Epogen for anemia. The facility failed to monitor the resident's hemoglobin levels prior to administering Epogen, as required by the physician's order and manufacturer guidelines. The MAR indicated that Epogen was administered on multiple occasions without any evidence that hemoglobin levels were checked beforehand. Both the registered nurse and the director of nursing confirmed that hemoglobin monitoring should have occurred weekly prior to each administration, but this was not done. The failure to monitor hemoglobin levels before administering Epogen was confirmed through interviews and record reviews.
Failure to Follow Standardized Portion Sizes for Egg Noodles
Penalty
Summary
The facility failed to follow its established menu and portion control procedures when a staff member did not level the number 8 scoop while serving egg noodles, resulting in portions larger than the standardized 1/2 cup specified in the recipe and menu. This was directly observed during trayline service, where the scoop was overflowing, and confirmed by the Dietary Supervisor, who acknowledged that the scoop should have been leveled. The facility's policies and procedures require adherence to standardized recipes and portion sizes to meet residents' nutritional needs and therapeutic diet requirements. This failure affected 64 out of 69 residents who received egg noodles, including 16 out of 20 residents on a consistent carbohydrate (CCHO) diet, which requires precise carbohydrate control for blood sugar management. The incident was documented through observation, staff interview, and review of facility records, including menus, recipes, and policies, all of which specified the correct portion size and the need for accuracy in food preparation and service.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified through observations and review of facility practices, which showed that residents were not always provided with meals that met their individual dietary needs and preferences.
Failure to Follow Professional Standards in Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or incidents were provided in the report.
Failure to Maintain Freezer Equipment Results in Ice Buildup and Food Storage Risk
Penalty
Summary
The facility failed to maintain the reach-in freezer according to the manufacturer's guidelines, resulting in a gap that allowed air to enter and caused significant ice buildup. Observations revealed ice accumulation by the door and shelves of the freezer, and interviews with the Dietary Supervisor confirmed ongoing issues with ice buildup due to air infiltration. The Dietary Supervisor acknowledged that a metal plate had been installed to prevent air from escaping, but a small gap remained, which was not acceptable as it could lead to food spoilage. The Maintenance Supervisor also confirmed the problem, stating that the freezer door was not sealing properly and that the gaskets were supposed to be changed, but instead, a metal plate was installed based on the administrator's decision. The Administrator stated that the issue with the freezer door not latching properly was discussed with the Maintenance Supervisor, and the decision was made to install a metal plate rather than consult the manufacturer for a solution. The Administrator was not aware that the ice buildup issue persisted. Review of facility policy indicated that equipment needing repair should be reported and maintenance records maintained, and the daily maintenance log showed ongoing awareness of the freezer's ice buildup problem. The deficiency had the potential to affect 64 of 69 medically compromised residents who stored food in the freezer.
Failure to Maintain Sanitary Food Service Conditions Due to Presence of Flies
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of flies in the kitchen during food preparation and trayline activities. During multiple observations, flies were seen flying around and landing on food preparation surfaces and equipment, including a pan and a blender. The Dietary Supervisor acknowledged that flies entered the kitchen when staff opened doors to bring in supplies such as ice and stated the importance of keeping the kitchen free from flies to prevent cross-contamination of food. A review of the facility's pest control policy indicated that an ongoing pest control program should be in place to keep the building free of insects and rodents. Additionally, the Food Code 2022 requires premises to be maintained free of pests through routine inspections and control measures. Despite these policies, the presence of flies in the kitchen during food service had the potential to affect 64 of 69 residents who received food from the kitchen.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for two residents with significant cognitive and physical impairments. For one resident with diagnoses including COPD, diabetes, and dementia, and who required maximal assistance with activities of daily living, the call light was observed behind the bed and out of reach. A CNA confirmed that the resident would not be able to access the call light in that position, and both the RN and DON stated that call lights should be within reach to allow residents to call for assistance. Similarly, another resident with diagnoses including CHF, COPD, epilepsy, and depression, and who required moderate assistance with daily activities, was also found to have the call light placed behind the bed and out of reach. The CNA present confirmed the resident could not reach the call light, and reiterated the importance of accessibility. Facility policy reviewed by surveyors stated that call lights should be within easy reach of residents when in bed or in a chair.
Failure to Develop and Implement Comprehensive Care Plans for Falls and Incontinence
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies related to falls and incontinence management. For one resident with a history of hemiplegia, hemiparesis, cerebrovascular accident, and a high risk for falls, the care plan did not include a post-fall intervention after the resident experienced an actual fall. Despite the facility's policy requiring immediate reassessment and care plan updates following a fall, no post-fall care plan was created. Staff interviews confirmed that the process was not followed, and the lack of a post-fall care plan meant that new interventions to prevent further falls were not implemented. Another resident, admitted with diagnoses including anxiety disorder, bipolar disorder, neuropathy, and psychosis, did not have a care plan addressing bowel and bladder incontinence management or retraining. The resident's assessment indicated a need for assistance with activities of daily living, but the care plan failed to include interventions for incontinence. The MDS Coordinator and DON both acknowledged that a comprehensive care plan should have been developed to address these needs, as required by facility policy. Facility policies reviewed during the investigation specified that care plans must be individualized, comprehensive, and include measurable objectives and timetables to address each resident's medical, nursing, mental, and psychological needs. The policies also required care plans to be updated promptly in response to changes in a resident's condition, such as after a fall or when incontinence is identified. The failure to follow these policies resulted in incomplete care planning for both residents.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and record reviews indicating that the care and services delivered did not consistently adhere to accepted professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report. The report notes a general failure to meet professional standards but does not include further factual observations or events related to the deficiency.
Failure to Ensure CNA Maintained Required ARC/AHA-Accredited CPR Certification
Penalty
Summary
The facility failed to implement its policy and procedure regarding cardiopulmonary resuscitation (CPR) by not ensuring that one of three Certified Nursing Assistants (CNA) had a valid CPR certification credentialed by the American Red Cross (ARC) or the American Heart Association (AHA). During a review of the CNA's CPR certificate, it was found that the training was not accredited by either the ARC or AHA, as required by the facility's policy. The Director of Nursing (DON) confirmed that CNAs are part of the facility's CPR team and that the policy mandates all staff to be trained by the ARC or AHA. Further interviews and record reviews with the Director of Staff Development (DSD) revealed that the CNA's CPR training did not meet the facility's accreditation requirements and that this oversight occurred during the hiring process. The facility's policy specifies that key clinical staff, including non-licensed personnel such as CNAs, must obtain and maintain ARC or AHA certification in BLS/CPR. The deficiency was identified through interviews and documentation review, confirming that the CNA was not properly credentialed according to facility policy.
Failure to Obtain Physician Order for Hemoglobin Monitoring Prior to Epogen Administration
Penalty
Summary
The facility failed to ensure that a resident with end stage renal disease, chronic obstructive pulmonary disease, and anemia received treatment and care in accordance with professional standards of practice. Specifically, the facility administered Epogen injections for anemia without obtaining a physician's order for hemoglobin monitoring, as required by both the medication's manufacturer's guidelines and the facility's own policy. The resident's records showed that Epogen was given on multiple occasions, but there was no corresponding order or documentation for regular hemoglobin level checks prior to administration. Interviews with nursing staff and the Director of Nursing confirmed that there was no physician order for hemoglobin monitoring and that Epogen should not have been administered without this monitoring. The facility's policy required medication orders to include follow-up requirements such as repeat labs or therapeutic medication monitoring, which was not followed in this case. The manufacturer's guidelines for Epogen also specified weekly hemoglobin monitoring until stable, then at least monthly, to ensure safe administration.
Failure to Initiate Bowel and Bladder Retraining Program for Eligible Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a bowel and bladder retraining program for a resident who was identified as a candidate for such intervention. The resident, who was admitted with diagnoses including anxiety disorder, bipolar disorder, neuropathy, and psychosis, was found to have intact cognitive functioning and the capacity to make decisions. Despite being always incontinent of bowel and bladder and dependent on staff for lower body dressing and transfers, the resident's assessment and screening indicated eligibility for a retraining program. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the retraining program was not initiated as required by facility policy and clinical guidelines. The facility's policy specified that staff should screen for and manage urinary incontinence, provide appropriate services to restore or improve bladder function, and document toileting trials. The failure to initiate the retraining program was acknowledged by staff and was not in accordance with the facility's established procedures.
Failure to Ensure Oxygen Delivery Device Was Connected for Resident Requiring Continuous Oxygen
Penalty
Summary
Facility staff failed to provide respiratory care consistent with professional standards for a resident with a history of respiratory failure with hypoxia, congestive heart failure, and dementia. The resident was dependent on staff for all activities of daily living and had a physician's order for continuous oxygen therapy via nasal cannula, with instructions to titrate as needed. During observation, the resident was found in bed with the nasal cannula placed near the nostrils, but the tubing was disconnected from the oxygen concentrator and hanging from the bed. Licensed staff confirmed that the oxygen tubing should always be connected to the oxygen source and that it is the responsibility of both licensed staff and certified nurse assistants to ensure the connection is intact. Interviews with the LVN and DON confirmed that staff are expected to routinely monitor oxygen tubing to ensure it is connected and functioning properly. Review of the facility's policy on oxygen administration indicated that staff should check tubing connections and ensure proper oxygen delivery. The failure to connect the nasal cannula to the oxygen concentrator was directly observed and acknowledged by staff, and the facility's own policy supports the need for such monitoring and connection.
Missed Annual Competency and Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete annual performance reviews and competency skills checks for two Certified Nursing Assistants (CNAs) within the required 12-month period. Specifically, one CNA had not received a competency skills check for the year following her last evaluation, and another CNA also missed her annual competency review. The Director of Staff Development (DSD) confirmed during interviews and record reviews that these evaluations were overdue and not present in the employee files. The DSD stated that competency checks are intended to ensure that CNAs and licensed nurses possess the necessary skills to perform patient care, medication administration, and other job duties, and that these should be completed annually based on hire date and filed immediately. The Director of Nursing (DON) also confirmed that annual performance reviews and competency checks are standard practice for all CNAs and licensed nurses, and that these evaluations are necessary to ensure staff are capable of providing appropriate care and treatment. Review of the facility's policy and procedure indicated that job descriptions and performance evaluations are used to clarify responsibilities, prevent misunderstandings, and provide a basis for job evaluation. The absence of timely performance reviews and competency checks was verified through employee file audits and staff interviews.
Failure to Monitor Hemoglobin Prior to Epogen Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not monitoring hemoglobin levels prior to administering Epogen, a medication used to treat anemia. The resident in question had diagnoses including end stage renal disease, chronic obstructive pulmonary disease, and anemia, and required varying levels of assistance with daily activities. According to the physician’s order, Epogen was to be administered weekly for anemia, with instructions to hold the medication if the hemoglobin level was greater than 11. However, review of the Medication Administration Record showed that Epogen was administered on at least two occasions without evidence that hemoglobin levels were checked beforehand. Interviews with nursing staff and the Director of Nursing confirmed that hemoglobin levels should have been monitored weekly prior to each administration of Epogen, in accordance with both the physician’s order and the manufacturer’s guidelines. The facility’s policy on medication administration also required medications to be given as prescribed and in a safe manner. The failure to monitor hemoglobin levels before administering Epogen constituted a deficiency, as it did not ensure the medication was indicated for the resident at the time of administration.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that medication administration errors remained below the acceptable threshold, as required by regulations. The deficiency was based on direct findings from the survey process.
Failure to Rotate Insulin Injection Sites Resulting in Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not rotating subcutaneous insulin injection sites as required by physician orders, manufacturer guidelines, and facility policy. Review of the resident's Medication Administration Record (MAR) showed repeated administration of insulin in the same anatomical areas, specifically the left upper and lower quadrants of the abdomen and the right arm, over multiple days. Interviews with nursing staff, including an LVN and an RN, confirmed that insulin administration sites should have been rotated with each dose, and acknowledged that this was not done for the resident in question. The resident involved had a history of diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure, and was cognitively intact and able to make decisions. Facility policies and the manufacturer's guidelines for insulin glargine (Lantus) both required rotation of injection sites to prevent adverse effects. The Director of Nursing also confirmed that failure to rotate sites constituted a medication error. The deficiency was identified through review of records, staff interviews, and examination of facility policies and procedures.
Therapeutic Diet Orders Not Properly Authorized
Penalty
Summary
Therapeutic diets were not consistently prescribed by the attending physician, nor was there documentation that the responsibility for prescribing these diets was properly delegated to a registered or licensed dietitian as permitted by State law. This resulted in a failure to ensure that dietary orders for residents requiring therapeutic diets were authorized in accordance with regulatory requirements.
Failure to Maintain Infection Control: Catheter Bag on Floor and Food in Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two specific deficiencies. First, staff did not ensure that an indwelling urinary catheter drainage bag for a resident with multiple complex medical conditions, including end stage renal disease, diabetes, dementia, and sepsis, was kept off the floor. Observations on two separate occasions found the drainage bag resting on the floor when the resident's bed was in its lowest position. Both a Licensed Vocational Nurse and a Registered Nurse acknowledged that this practice was not in accordance with facility policy and posed an infection control risk, as bacteria from the floor could contaminate the bag and potentially lead to infection. The facility's own procedures and policies explicitly required that catheter drainage bags be kept off the floor to prevent catheter-associated urinary tract infections. Additionally, the facility failed to maintain sanitary storage practices in the clean linen closet. During an inspection, food items including a bagel, banana, and a bottle of Gatorade were found stored alongside clean linens, beddings, towels, gowns, and residents' personal clothes. The Maintenance Supervisor confirmed that these food items belonged to an assistant and admitted to having previously instructed the assistant not to store food in the linen closet. The Director of Nursing also confirmed that food should not be stored in this area, as it could attract insects and compromise the cleanliness of residents' clothing and linens. Review of facility policies indicated that all housekeeping and laundry storage areas were to be kept clean and free from trash, rubbish, and other contaminants at all times. The presence of food in the clean linen storage and the improper handling of the catheter drainage bag both represented failures to follow established infection control procedures, as documented in the facility's own policies and procedures.
Resident Room Size Below Regulatory Standards
Penalty
Summary
The facility failed to provide rooms that meet the required minimum square footage per resident. Specifically, rooms intended for multiple residents did not meet the standard of at least 80 square feet per resident, and single resident rooms did not meet the required 100 square feet. This deficiency was identified based on the physical measurements of resident rooms during the survey.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted nursing staffing information was accurate and up to date. During observations and interviews with facility staff, it was found that the posted nursing staffing information in the front lobby was dated several days prior and did not reflect the current date. Both the Minimum Data Set Coordinator and the Director of Staff Development confirmed that the information should have been updated to reflect the current day's staffing and that it is their responsibility to ensure the information is posted daily and accurately. A review of the facility's policy and procedure indicated that nursing staffing numbers are to be posted daily for each shift, with the shift supervisor responsible for computing and posting the numbers within two hours of the start of each shift. The failure to update the posted information resulted in inaccurate staffing data being available to residents, visitors, and staff, contrary to facility policy and regulatory requirements.
Failure to Administer and Document Physician-Ordered Treatments and Notify Provider of Critical Lab Results
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for two residents. For one resident with chronic conditions including COPD, diabetes, and dementia, the facility did not document administration of a prescribed Betadine treatment for a toe wound on a specific date, as required by the care plan and treatment administration record (TAR). The responsible LVN confirmed the absence of documentation and stated that the treatment was not recorded as given, which was contrary to facility policy requiring all topical treatments to be documented on the TAR. Additionally, the same resident had physician orders for regular blood sugar (BS) monitoring and specific instructions for notifying the provider if certain BS thresholds were met. Despite multiple elevated BS readings over several days, there was no record of provider notification as required by the order. Both the LVN and an RN confirmed that the provider should have been notified of these results, and the facility's diabetes protocol required staff to report such findings. For a second resident with diagnoses including anxiety disorder, alcoholic cirrhosis, and splenomegaly, the facility failed to document administration of a prescribed topical antibiotic (Mupirocin) for a toe infection on a specific date. The LVN confirmed the lack of documentation on the TAR, indicating the treatment was not recorded as administered. Facility policy required all medications, including topical treatments, to be administered as prescribed and documented accordingly.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan for one of two sampled residents within 48 hours of admission. Specifically, a resident with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety disorder, schizophrenia, and impaired cognitive functioning was admitted and later readmitted, but the baseline care plan was not completed within the required timeframe. Additionally, the comprehensive care plan was not updated after the resident's readmission. This was confirmed through record review and staff interview, where a Licensed Vocational Nurse acknowledged the omission and stated that the baseline care plan had not been completed as of several days after readmission. The facility's own policy requires a baseline care plan to be developed within 48 hours to address immediate health and safety needs.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect two residents from physical abuse when a verbal altercation in the smoking patio escalated into a physical confrontation. One resident, who had moderately impaired thought processes and required moderate assistance with activities of daily living, was grabbed by the neck and choked by another resident. This resulted in the victim falling to the ground, experiencing pain in the right knee, and feeling shocked and scared. The incident was witnessed by another resident, who reported that staff were not present in the smoking patio at the time of the altercation and that no staff could be found at the nurses' station immediately after the event. The resident who was attacked had a history of osteoarthritis and hypertension and was assessed as having the capacity to understand and make decisions. After the incident, the resident reported pain and emotional distress, and a post-fall evaluation confirmed mild pain in the right knee. The aggressor, who also had moderately impaired thought processes and required supervision for transfers and ambulation, was reported to have left the area immediately after the incident. Staff interviews confirmed that the event was not witnessed by staff, and the initial response was triggered by a certified nursing assistant who heard a noise and found the victim on the floor. Both the Administrator and the DON acknowledged that staff should have been present in the smoking patio to ensure resident safety, as required by the facility's abuse prevention policy. The policy specifically states that residents have the right to be free from abuse, including abuse by other residents, and that the administration is responsible for protecting residents from such incidents. The lack of staff supervision in the smoking patio directly contributed to the occurrence of physical abuse between residents.
Failure to Develop and Implement Care Plan for Self-Administration of Medication
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had received a physician's order to self-administer inhaler medications. Despite documentation indicating the resident was capable of self-administering medications, including storing them securely, managing containers, and understanding medication schedules and refusals, there was no corresponding care plan addressing this aspect of care. The resident's medical record included a diagnosis of hypertension and COPD, with assessments showing moderately impaired thought processes and a need for maximal assistance with activities of daily living. Record reviews and interviews confirmed that the care plan did not reflect the physician's order or the resident's ability to self-administer medication, as required by facility policy. The Director of Nursing acknowledged that the care plan should have been updated to address the resident's physical and psychological needs related to self-administration of medication. Facility policies reviewed also specified that such care plans must be developed and implemented when self-administration is deemed safe and appropriate.
Failure to Administer Antibiotic as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering cephalexin 500 mg oral tablets at the scheduled times as ordered by the physician. The resident, who had diagnoses including chronic obstructive pulmonary disease, systemic lupus erythematosus, and type 2 diabetes mellitus, was admitted with a bladder infection and had a physician order for cephalexin to be given four times daily. Review of the medication administration history showed that the medication was administered late on multiple occasions, sometimes more than an hour after the allowed administration window, and in one instance, two doses were given together late at night. The facility's policy required medications to be administered within one hour of the scheduled time, and deviations were to be documented appropriately. Interviews with the MDS nurse, DON, and facility pharmacist confirmed that the medication was not administered within the required time frames on several dates. The DON acknowledged that the late administration of the medication could result in ineffective treatment, and the pharmacist noted that administering doses too close together could cause adverse effects such as abdominal pain and diarrhea. The facility's failure to follow physician orders and its own policy led to the resident not receiving timely medication as prescribed.
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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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