Villa Del Sol Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellflower, California.
- Location
- 16910 Woodruff Ave., Bellflower, California 90706
- CMS Provider Number
- 055918
- Inspections on file
- 49
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Villa Del Sol Post Acute during CMS and state inspections, most recent first.
A resident with osteogenesis imperfecta, intact cognition, and dependence for ADLs reported right hip pain and stated to PT and nursing staff that hospital nurses had handled her roughly, while her family also reported she had not been handled properly and that her hip was normal before that hospitalization. Nursing assessment later identified a protruding, red, and warm right hip, an X‑ray was ordered, and imaging confirmed an acute displaced proximal femur fracture, after which the resident was transferred to another hospital. Despite the facility’s policy requiring immediate reporting of all abuse allegations and injuries of unknown source, the PT did not report the resident’s statements, and the DON did not notify CDPH of either the abuse allegation or the hip fracture, relying in part on consultant advice that the fracture did not need to be reported.
A resident with dementia, muscle weakness, difficulty walking, incontinence, and a documented high fall risk required one-person assistance with ADLs and had a care plan and IDT recommendations for frequent visual checks and timely assistance after an unwitnessed fall with an elbow skin tear. Despite this, surveyors observed the resident’s room door closed while the resident stood barefoot at the foot of the bed after using the bathroom. The responsible party reported the door was often closed, an LVN acknowledged the door should have been kept open for safety, a CNA admitted he knew the resident was a fall risk but did not communicate the resident’s preference for a closed door to licensed staff, and an RN supervisor reported seeing the resident close her door multiple times without initiating a care plan change, resulting in inadequate visibility and supervision contrary to facility fall prevention and accident policies.
A resident with dementia, polyneuropathies, muscle weakness, difficulty walking, incontinence, and a documented high fall risk had a care plan identifying fall and injury risk with general interventions such as anticipating needs, providing proper footwear, and maintaining a safe environment. After the resident experienced an unwitnessed fall resulting in a left elbow skin tear, an IDT conference documented that the resident was impulsive, had a balance deficit, and attempted to ambulate beyond her capabilities, and recommended frequent visual checks, timely assistance, and reminders about safety precautions. Despite this, the resident’s care plan was not revised to include these updated fall-prevention interventions, and a CNA reported not knowing how often to check on the resident, contrary to facility policies requiring comprehensive, revised care plans and updated fall prevention measures.
Multiple residents and a family member reported repeated loss of labeled clothing, personal items, and a purse with checks, but staff did not document these concerns as grievances, did not enter them into the grievance log, and did not complete required investigations or timely resolutions. Interviews showed that the SSA was unclear on the grievance process, the DON acknowledged that missing property complaints should have been handled as grievances but were not, and the ADM confirmed that Social Services was expected to follow up and reimburse or replace lost items. The facility’s written grievance policy required staff to document verbal or written grievances, forward them to a designated Grievance Official, investigate, keep residents informed, and issue written decisions, yet these steps were not followed for the reported missing property concerns, leaving the issues unaddressed.
A resident with severe cognitive impairment, incontinence, and dependence on staff for ADLs was left undressed from the waist down and lying on urine-soiled linens for several hours, despite care plans requiring frequent incontinence checks, perineal care, and linen changes. The CNA assigned to the resident did not check on her from the start of the shift and acknowledged the resident remained on soiled linens placed by the prior shift. An LVN passed medications without assessing the resident’s condition, did not assist the CNA who was running behind, and did not report delays, resulting in the resident missing a scheduled shower. These actions and inactions occurred despite facility policies on incontinence care, ADLs, resident rights, dignity, and maintaining a clean, sanitary environment.
A resident with generalized muscle weakness, partial foot amputations, UTI, and CKD, who required supervision to touch assistance for ADLs, had a care plan directing that the call light be kept within reach due to fall and injury risk. During observation, the call light was found on the floor out of reach, and the resident reported needing it under the forearm to request help, including assistance to empty a urinal, and having searched for it repeatedly. A CNA stated that, because the resident’s body covered the bed, the call light had been placed on the bedside table earlier in the day, and acknowledged it should have been placed within reach, contrary to facility policy and the DON’s expectation that all residents have accessible call lights checked hourly.
A resident capable of making her own decisions did not have a valid POLST on file, as it was signed by a family member acting only as an interpreter. During a medical emergency, staff were unable to promptly determine the resident's code status and delayed CPR while consulting with family members, despite the presence of a DNR order signed by an unauthorized individual. Paramedics performed CPR upon arrival, but the resident expired.
A resident with dementia and other complex conditions was given Ativan, a psychotropic medication, without a clearly documented indication or consistent monitoring of behaviors and side effects. Facility records and staff interviews revealed that the required manifestations for medication use were not specified in the orders or medical records, and monitoring practices did not meet facility policy requirements.
Staff failed to properly handle and dispose of a soiled gown, which was observed left on the floor of a resident room near the trash can instead of being placed in the designated soiled linen bin. A CNA and an LVN both acknowledged this as an infection control issue, and the facility's policy requires soiled linens to be collected and stored in a sanitary manner to prevent infection spread.
A resident with a history of mental health conditions and wandering behavior eloped from the facility due to inaccurate risk assessment and inconsistent care planning. Staff failed to provide adequate supervision, and conflicting documentation led to inappropriate interventions. The resident was able to leave the facility unsupervised when staff did not notice his absence, and the facility's policies for assessment and supervision were not properly followed.
A resident with a history of cerebral infarction and atrial fibrillation was denied readmission to the facility after being cleared for discharge from a hospital, even though beds were available. Staff interviews revealed that the resident's bed hold had expired and there was an outstanding share of cost, but these factors should not have prevented her return. The resident experienced significant emotional distress, including sadness and anxiety, as a result of being denied readmission and losing her place of residence.
The facility did not complete required annual Legionella water testing as outlined in its policies, with staff and contracted vendors confirming the missed testing and lack of clarity on requirements. Additionally, a resident on Enhanced Barrier Precautions due to multiple medical conditions had visitors who were not wearing PPE during direct contact, despite staff awareness of the need for enforcement and education. These lapses resulted in compromised infection control practices.
Two residents did not have their care plans updated to address essential needs, including oral hygiene and refusal of care for one resident with severe cognitive and physical impairments, and a change to a puree diet with one-on-one feeding for another resident with metastatic cancer and swallowing difficulties. Staff interviews and observations confirmed that these interventions were not documented or implemented as required by facility policy.
Annual performance evaluations were not completed for two CNAs, as confirmed by personnel file reviews and staff interviews. The facility's assessment tool and staff policies require regular competency validation, but this was not carried out as required.
Two residents experienced medication errors when an LVN administered several medications later than the prescribed time window and another LVN gave the wrong formulation of a cough medication. These actions resulted in a medication error rate of 17.65%, exceeding the acceptable threshold, and were attributed to deviations from physician orders and facility policy.
Nursing staff failed to administer medications as ordered, including giving a pain medication late to a resident and not holding antihypertensive medications for two residents when their blood pressure readings were below physician-ordered parameters. These actions resulted in significant medication errors, as confirmed by staff interviews and medication administration records.
Surveyors found multiple deficiencies in kitchen food safety practices, including expired ham stored in the refrigerator, dirty cooking equipment and food preparation areas, a worn can opener blade, improper hot holding temperatures for TCS foods, and ineffective sanitizer solution used for cleaning food contact surfaces. These issues were confirmed by dietary staff and were not in compliance with facility policy or FDA Food Code.
The QAA and QAPI committees failed to maintain oversight of previously identified systemic issues, including high medication error rates, deficiencies in food and nutrition services, and lapses in the antibiotic stewardship program. These issues, which had been part of the facility's prior plan of correction, were no longer actively managed, resulting in continued deficiencies affecting all residents.
Two residents received antibiotics without proper documentation of indication, duration, or monitoring for adverse reactions. One resident was prescribed Bactrim without an antibiotic time-out or clear reason for use, and another received prophylactic Bactrim without a care plan or monitoring for side effects, contrary to facility policy.
A resident with paralysis and weakness was found in bed without a call light within reach, requiring them to call out loudly for help. Staff confirmed the call light was behind the headboard and not accessible, and acknowledged the importance of keeping it within reach. Facility policy also requires call lights to be accessible to residents.
A resident with multiple mental health diagnoses and moderate cognitive impairment was admitted without an accurate Level 1 PASARR screening. The screening incorrectly indicated no serious mental illness, preventing a required Level 2 evaluation and potentially delaying appropriate mental health services. Facility staff confirmed the screening was not completed correctly, contrary to facility policy.
A resident with severe cognitive impairment and total dependence on staff for activities of daily living was found with poor oral hygiene, including visible food particles and debris on the teeth and lips. Staff interviews and record reviews confirmed that required oral care was neither provided nor documented, and there was no record of care refusals, contrary to facility policy and expectations.
A resident dependent on staff for feeding and with a history of dysphagia was observed being fed in bed while lying on their side with the head of the bed at a low angle, contrary to their care plan and facility policy. Staff interviews confirmed this was not a safe feeding position and could cause swallowing difficulties. The failure to position the resident upright during feeding resulted in a deficiency related to accident prevention and adequate supervision.
A resident with documented allergies to Aspirin and Acetaminophen was prescribed Tylenol by a PMD, but the order was not carried out due to the allergy. Nursing staff notified the PMD but did not follow up for three days to secure an alternative pain medication, contrary to facility policy. This resulted in the resident's pain management needs not being addressed in a timely manner.
An expired fluticasone/salmeterol inhaler prescribed for a resident with asthma was found in a medication cart during an inspection. The inhaler had not been removed after the recommended one-month period post-opening, and the LVN was unaware of the expiration timeframe. This was not in accordance with manufacturer guidelines or facility policy, which require timely removal and destruction of expired medications.
A resident with Parkinson's Disease and dysphagia, requiring a vegetarian and minced and moist diet, was not provided with appropriate menu options or food textures. The kitchen failed to prepare a vegetarian protein alternative, instead serving chopped carrots and, on another occasion, minced shrimp, neither of which met the resident's dietary needs. Staff and dietary supervisors were unaware or did not notice the errors, and the resident's meal tickets clearly indicated the required diet. The food provided did not meet facility policy or the resident's prescribed dietary requirements.
Two residents with significant mobility impairments and pressure ulcers did not have individualized, resident-centered care plans. Instead, their care plans included interventions such as encouraging self-repositioning and education on skin care, which were not feasible due to their dependence on staff for mobility. Staff interviews confirmed the care plans did not reflect the residents' actual needs.
A resident with Parkinson's disease and significant ADL needs experienced a progression of a pressure ulcer from stage 1 to stage 3, but the care plan was not updated to reflect the change or include new interventions. Staff interviews confirmed the care plan should have been revised, in accordance with facility policy.
A resident with Parkinson's disease and existing pressure injuries was not assessed by a treatment nurse for skin and wound status in a timely manner after readmission. Despite facility policy and staff expectations for prompt assessment, the required evaluation was delayed, resulting in a deficiency related to pressure ulcer care and documentation.
Two residents' rights were violated when a facility removed Sit-to-Stand lifts without addressing their concerns, forcing them to use Hoyer lifts. Despite their ability to understand and make decisions, the residents experienced anxiety and discomfort. Staff interviews revealed that the facility did not allow residents to refuse the Hoyer lift, leading to delays in care. The Administrator admitted to failing in communication, acknowledging that residents' concerns were not heard before the decision.
A resident at risk for pressure injuries was left sitting in a wheelchair for four hours due to the facility's inadequate planning during the transition from Sit to Stand (SS) lifts to Hoyer lifts. The resident, with a history of hemiplegia and diabetes, expressed discomfort and anxiety about the change, as the Hoyer lift required more staff and caused delays in care. The facility's lack of anticipation for staffing needs led to increased risk of skin breakdown, contrary to their policy on pressure injury prevention.
A resident at risk for falls, with severe cognitive impairment and requiring assistance, sustained a head injury after getting out of bed unassisted. The facility failed to follow the care plan's intervention for increased monitoring frequency, resulting in the resident being found on the bathroom floor. Staff interviews revealed a lack of awareness and communication about the resident's monitoring needs, and there was no documentation of visual checks.
A resident who underwent knee replacement surgery experienced severe pain due to the facility's failure to provide timely pain management. The resident's prescribed medication was delayed for over two hours because the keys to the medication cart were not properly endorsed during a shift change, and the Registered Nurse Supervisor left with the keys. This resulted in increased pain and anxiety for the resident, who was unable to receive the necessary medication until the keys were returned.
A resident with multiple health conditions, including ESRD, missed two hemodialysis sessions due to transportation errors. Despite the resident's cognitive ability to make decisions, the facility did not hold an IDT meeting to address the missed sessions or involve the resident in care planning, violating their right to participate in their person-centered care plan.
The facility failed to aggressively treat skin breakdown and prevent the progression of contact dermatitis for two residents. Despite multiple evaluations and changes in treatment orders, the residents continued to experience intense itching and scratching. The facility delayed consulting a dermatologist and did not reassess treatment interventions in a timely manner, contributing to the persistence of the residents' conditions.
The facility failed to document a medical condition for a resident's use of mirtazapine and did not monitor the medication's effectiveness or adverse effects. The resident, diagnosed with Alzheimer's, was prescribed mirtazapine for depression without supporting documentation. The facility also did not monitor the resident's behavior or adverse effects, increasing the risk of harm.
A facility failed to maintain a medication error rate below five percent, resulting in an error rate of 26.67%. A resident experienced eight medication errors, including omitted doses and late administration of various medications. The errors were due to medication unavailability and high workload, and the LVN incorrectly marked the MAR. The DON confirmed that the facility's policy was not followed.
A resident did not receive ten doses of Symbicort inhaler as prescribed between 4/1/2024 and 4/10/2024 due to the medication not being available in the facility. The LVN erroneously marked the MAR as if the medication had been administered, and the issue was not reported to the pharmacy, physician, or DON.
The facility failed to remove expired insulin, improperly stored unopened insulin, and left Hydrocortisone cream at a resident's bedside without a physician's order. These actions affected multiple residents and posed risks of ineffective medication and potential medical complications.
The facility failed to follow the lunch menu and portion sizes for residents on mechanical soft and pureed diets, serving less protein than required. The cook used smaller scoops than indicated in the food portion and serving guide, which was confirmed by the RD and DS.
The facility failed to prepare pureed food by methods that conserved texture and appearance, resulting in a lumpy and chunky consistency that required chewing before swallowing. This placed seven residents on the pureed diet at risk for choking and meal dissatisfaction.
The facility failed to ensure safe and sanitary food storage and preparation practices, including storing expired and improperly labeled food items, not following proper handwashing procedures in the dishwashing area, and not managing food brought in from outside the facility. These deficiencies were acknowledged by the Dietary Supervisor and the Activity Director.
A facility failed to ensure the accuracy of the MAR for a resident with asthma and macular degeneration. Symbicort and Preservision AREDS2 vitamins were documented as administered multiple times despite being unavailable. The LVN admitted to marking the MAR inaccurately due to workload, and the DON confirmed the failure to follow proper procedures.
The facility failed to offer pneumonia vaccinations to two residents, both of whom were severely cognitively impaired and unable to make decisions for activities of daily living. The Infection Preventionist admitted that the vaccine was not offered this year, and no follow-up was conducted. The Director of Nurses confirmed that the facility's policy required the vaccine to be offered three times and documented if refused, which was not done.
A facility failed to ensure a resident had a functioning call light, compromising the resident's ability to obtain necessary care. The resident, with multiple diagnoses and severe cognitive impairment, was found to have a non-functional call light despite being dependent on all aspects of daily living. Staff and maintenance were aware but did not properly address the issue.
The facility staff failed to notify a resident and her family about a room change, causing distress and confusion. The resident, who lacked decision-making capacity, was moved without prior notice or explanation, and her family was not informed, leading to additional concern. The facility's policy on resident rights was not followed.
The facility failed to create a resident-centered care plan for a resident prescribed mirtazapine to treat depression and withdrawal from activities of interest. Despite the resident's Alzheimer's diagnosis and lack of decision-making capacity, no care plan was developed to address these issues, increasing the risk of adverse effects from the medication.
The facility failed to properly position a resident while eating, risking aspiration and choking, and did not conduct a thorough assessment for another legally blind resident, leading to a fall. Staff confirmed that the care plans were not adequately updated to reflect the residents' needs.
The facility failed to accurately account for one dose of hydrocodone/apap 5/325 mg for a resident. An LVN admitted to administering the missing dose but failed to sign the Controlled Drug Record immediately due to being distracted. This failure to document immediately is against the facility's policy, increasing the risk of medication errors and potential diversion.
The facility failed to ensure a medication regimen review (MRR) was completed and documented upon admission for a resident with multiple health conditions and 29 active medication orders. The Director of Nursing confirmed the absence of the required MRR documentation, which increased the risk of adverse effects related to the resident's medication therapy.
Failure to Report Abuse Allegation and Hip Fracture of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of physical abuse and an injury of unknown origin for a resident with osteogenesis imperfecta who was admitted with extremely fragile bones and intact cognition, and who was dependent on staff for ADLs. Shortly after admission, during a PT evaluation, the resident reported right hip pain and stated that she had been handled roughly by nurses at a prior general acute care hospital (GACH 1); the PT did not report this allegation to supervisory staff, assuming the pain was related to the resident’s underlying condition. Later, nursing documentation showed that the resident’s family member reported the resident had not been handled properly at GACH 1 and that the resident’s hip was not abnormal prior to that hospitalization. Subsequently, nursing assessment identified a prominent protrusion, redness, and warmth of the resident’s right hip, and the physician ordered an X‑ray. Radiology results confirmed an acute displaced fracture of the proximal shaft of the right femur, and the resident was transferred to another hospital for further evaluation and treatment. Despite the resident’s statements that she had been roughly handled by nurses at GACH 1, her denial of any fall or other incident to explain the fracture, and the facility’s policy requiring immediate reporting of all allegations of abuse and injuries of unknown source, the DON acknowledged that CDPH was not notified of either the hip fracture or the abuse allegation. The DON stated that a consultant had advised that the fracture did not need to be reported and that, while the allegation of rough handling should have been reported, it was missed while focusing on the fracture.
Failure to Maintain Door Open for High Fall-Risk Resident, Limiting Staff Visibility
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and observable environment for a resident with a known high fall risk by allowing her room door to remain closed, limiting staff visibility. The resident was admitted with dementia, polyneuropathies, muscle weakness, and difficulty walking, and her MDS showed she was unable to make reasonable decisions, required one-person assistance with ADLs, and was incontinent of bowel and bladder. A fall risk assessment documented a high fall risk score of 16 due to a history of falls, intermittent confusion, poor standing balance, and multiple medications and comorbidities. Her care plan identified risk for falls and injury, with goals for her to remain free from falls and serious injury, and interventions such as anticipating and meeting needs, providing appropriate footwear when ambulating, and maintaining a safe environment. Despite these identified risks, the resident experienced an unwitnessed fall, reported on a Change in Condition Evaluation, in which she sustained a left elbow skin tear. Following this event, IDT notes documented that she was impulsive, had a balance deficit, and attempted to ambulate beyond her capabilities and without assistance. The IDT recommended frequent visual checks, timely assistance as needed, and reminders to nursing staff regarding her safety precautions and plan of care. However, interviews and observations later showed that these recommendations were not consistently supported by maintaining her room door open for visibility. On observation, the resident’s room door was found closed while she was standing barefoot at the foot of her bed, having just come from the bathroom, and she did not know why the door was closed. Her responsible party reported that on multiple visits the door was always closed and expressed concern that staff could not monitor the resident. An LVN confirmed the door was closed and stated staff should have kept it open because the resident was a fall risk and should be visible at all times. A CNA stated he knew the resident was a fall risk from the nursing huddle but did not know how often to check on her, acknowledged that the resident wanted her door closed, and admitted he did not inform licensed staff of this despite her confusion and fall risk. The RN supervisor reported having observed the resident closing her door multiple times and had not yet contacted the responsible party or physician or developed a plan of care to address this safety concern, and acknowledged that staff could not monitor the resident or attend to her needs in a timely manner if her door remained closed. The DON stated the CNA should have informed the LVN about the closed door and that staff should work together to keep care areas accessible, consistent with facility policies on accidents, supervision, and fall prevention that require identification of risks, implementation of interventions, and increased rounds.
Failure to Update Care Plan After Fall for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a high fall-risk resident’s care plan after an unwitnessed fall. The resident, who had dementia, polyneuropathies, muscle weakness, difficulty walking, and was incontinent of bowel and bladder, was admitted with a documented high fall risk score of 16 due to a history of falls, intermittent confusion, poor standing balance, and multiple medications with several predisposing diseases. A care plan dated 1/26/2026 identified the resident as at risk for falls and injury, with interventions such as anticipating and meeting needs, providing appropriate footwear when ambulating, and maintaining a safe environment. On 1/31/2026, a Change in Condition Evaluation documented that the resident reported having fallen earlier that morning and sustaining a left elbow skin tear. Following this fall, an Interdisciplinary Care Conference note dated 2/2/2026 documented that the resident was impulsive, had a balance deficit, and attempted to ambulate beyond her capabilities and without assistance, with recommendations for frequent visual checks, timely assistance, and reminders to nurses regarding safety precautions and the plan of care. However, review of the resident’s care plan showed no revisions or updates to the fall risk interventions after the fall event. A CNA reported knowing only that the resident was a fall risk from shift huddles but was unaware of how often to check on the resident. The RN Supervisor and DON both stated that the resident’s fall risk interventions should have been revised and updated after the fall and once the IDT identified the resident’s safety needs. Facility policies on comprehensive care plans and the fall prevention program required development, implementation, and revision of person-centered care plans and updating care plans as indicated, which was not done in this case.
Failure to Implement Effective Grievance Process for Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective grievance process to ensure resident concerns, specifically about missing personal property, were documented, investigated, and resolved in a timely manner. The facility’s own grievance logs from January to March 2026 showed no grievances related to missing personal property for three sampled residents, despite multiple reports of lost items. The facility’s policy stated that a Social Services designee serves as the Grievance Official, responsible for receiving, tracking, investigating, and resolving grievances, and that staff who receive a grievance must document it and forward it for follow-up. However, staff interviews and record reviews confirmed that these steps were not carried out for the missing property concerns. One resident with Alzheimer’s disease, dementia, major depressive disorder, and impaired cognition, who required assistance with ADLs and was occasionally incontinent, had all personal property reported missing by a family member. The missing items included labeled clothing, a hamper, slippers, blankets, robes, tank tops, and underwear. The family member stated the facility laundered the items and did not return them, that the resident was wearing clothing that did not belong to her, and that the family had to purchase replacement items. The family member reported the issue to multiple staff, including the charge nurse and the Administrator, and stated the Administrator was condescending and lacked empathy. The family member reported that the missing items, valued at approximately $350.45, had not been reimbursed, and the issue remained unresolved. Another resident with orthopedic aftercare following amputation, type 2 DM with hyperglycemia, and hypertensive heart disease, who had moderately impaired cognition and required maximal assistance for bathing and personal hygiene, reported that her purse and wallet had been missing for about three weeks. The missing items contained two checks. She stated she reported the loss to the facility, staff searched but did not locate the items, and she had not been reimbursed. She also stated she did not feel her property was safe and that social services did not assist her with the loss or with canceling the checks. A third resident with DM, bipolar disorder, and schizophrenia, who had intact cognition but was dependent or required maximal assistance for ADLs, reported that personal items such as hair clippers, styluses, and tweezers had been misplaced on multiple occasions over about five months, often after hospital transfers when belongings were packed. He stated he reported the missing items to staff, was told the issue would be reported to a supervisor, but received no follow-up and multiple items remained missing. The Social Services Assistant stated that when items were reported missing, staff should search laundry and rooms, check inventory sheets, and reimburse residents if listed items could not be located, and that missing items should be documented in progress notes and reported to Administration. The SSA acknowledged discussing missing clothing with the family member of the first resident and being aware of missing money and items for the third resident, but did not indicate that grievances had been initiated and stated she was unaware of a missing purse or checks for the second resident. She further acknowledged that grievances should be initiated when residents or families report concerns, including missing property, and that if missing items had been reported, they should have been documented and a grievance filed. The SSA admitted she did not usually handle grievances, was unsure of the grievance process, and that grievances for these missing property concerns had not been documented, resulting in a lack of follow-up and unresolved concerns. The DON stated that when a complaint cannot be resolved immediately, the grievance process should be followed and that missing personal property should have been handled as a grievance because it required investigation and follow-up. The DON acknowledged that no grievances were filed for the missing property complaints from the three residents and that the lack of a grievance process meant the issues were ignored and unresolved. The Administrator stated that when property is lost, Social Services should follow up and, if needed, replace or reimburse the resident, and that the grievance process should be used to ensure timely and efficient handling. The facility’s written grievance policy specified that residents and family members may voice grievances verbally or in writing regarding care, treatment, or other concerns, that staff receiving a grievance must document it and take immediate action as needed, and that the Grievance Official must investigate, follow up, keep the resident informed of progress, and provide a written decision with findings and corrective actions. Despite these requirements, the missing property concerns for the three residents were not entered into the grievance system, not documented as grievances, and not resolved through the required process.
Failure to Provide Timely Incontinence Care, Hygiene, and Dignified Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living, incontinence care, and hygiene for a cognitively impaired resident, resulting in the resident being left undressed from the waist down and lying on urine-soiled linens for several hours. The resident had diagnoses including Alzheimer’s disease, dementia, major depressive disorder, and difficulty walking, and assessments documented that she lacked decision-making capacity, had severely impaired cognition, and required moderate assistance for toileting, bathing, dressing, personal hygiene, sit-to-stand mobility, and toilet transfers. Care plans identified her as being at risk for skin breakdown and urinary tract infection related to occasional bowel and bladder incontinence, with interventions directing staff to check her at least every two to three hours for incontinence, provide perineal care after each episode, and change clothing and linens as needed. On the morning of the survey observation, the resident was found in her room with the door closed and strong air blowing from the vents, stating she was cold. She was observed wearing only a thin blue shirt and was undressed from the waist down, without briefs or underwear. Her bed sheets were soiled with yellowish stains, which were covered by a towel and a chucks pad. Later that day, during a concurrent observation and interview, the resident remained undressed from the waist down on the same soiled linens covered with a towel and chucks pad. The CNA assigned to the resident acknowledged she had not checked on the resident since the start of her shift at 7 a.m. and stated that the towel and chucks pad had been placed by the previous shift. The CNA stated it was not appropriate for the resident to be left lying on soiled linens without a brief and undressed from the waist down, and acknowledged that leaving the resident unattended on wet, soiled linens was unsanitary and could affect the resident’s dignity, comfort, and emotional well-being. The LVN assigned to the resident stated the resident should not have been left undressed from the waist down or lying on soiled, wet linens, and acknowledged that the resident had remained unchecked for approximately five hours, despite the LVN having passed medications at 9 a.m. without checking the resident’s condition. Review of the bathing schedule and ADL bathing flow sheet for that day showed the resident had been scheduled for a shower that morning but did not receive it because the CNA was running behind, and the LVN did not assist or report the delay, despite stating it was her responsibility to do so when nursing assistants were behind. These events occurred despite facility policies requiring prompt cleansing after incontinence, maintenance of personal hygiene and ADLs, treatment with dignity and respect, and prompt attention to soiled linens in order to maintain a clean, sanitary, and comfortable environment.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in which staff failed to keep a resident’s call light accessible and within reach as care planned. The resident had diagnoses including generalized muscle weakness, acquired absence of multiple toes on both feet, UTI, and CKD, and an MDS dated 2/26/2026 showed intact cognition with a need for supervision to touch assistance for ADLs. The resident’s care plan, dated 11/20/2025, documented a risk for falls/injury related to impaired balance and included an intervention to place the call light within reach and encourage its use for assistance as needed. During an observation and interview on 3/9/2026 at 2:45 p.m., the resident’s call light was found on the floor away from the resident, and the DSD acknowledged it was out of reach. At 2:55 p.m., the resident reported he needed the call light under his forearm so he could press it when needing assistance and stated he was looking for the call light every 20 minutes and needed it to get help to empty his urinal. In a 3:47 p.m. interview, the DON stated all residents must have accessible call lights within reach and that staff are instructed to check call lights every hour. At 3:55 p.m., CNA 1 reported that because the resident was large and his body covered the entirety of the bed, he had placed the call light on the bedside table at approximately 11 a.m., thinking it would fall off the bed, and acknowledged he should have placed it within the resident’s reach. Review of the facility’s “Call Light: Accessibility and Timely Response” policy dated 12/19/2022 indicated call lights must be within residents’ reach.
Failure to Obtain Valid POLST and Determine Code Status Delays Life-Sustaining Treatment
Penalty
Summary
The facility failed to obtain a credible Physician Orders for Life-Sustaining Treatment (POLST) for a resident who was capable of signing her own consent. Instead, the POLST was signed by a family member who was only designated as the resident's emergency contact and served as an interpreter, not as the responsible party. The POLST indicated a Do Not Resuscitate (DNR) order and comfort-focused treatment, but the resident's own wishes were not directly documented due to this procedural error. During a medical emergency, staff were unable to determine the resident's code status promptly. Instead of having clear documentation, staff inquired with two family members at the bedside and by phone about whether to initiate CPR. This led to confusion and a delay in starting life-sustaining procedures. Interviews with staff and family confirmed that the family member who signed the POLST was not authorized to make such decisions, and that staff routinely contacted families during emergencies to confirm or change code status, contrary to established policy and the resident's rights. The resident, who had diagnoses including type 2 diabetes, generalized muscle weakness, and anxiety disorder, was noted to have moderately impaired cognition but was still capable of making her own decisions. During the emergency, CPR was not initiated until after family consultation, despite the presence of a DNR order signed by an unauthorized party. Paramedics eventually performed CPR upon arrival, but the resident expired at the facility. Facility policy and state law require that POLST forms reflect the patient's preferences and be followed by healthcare providers.
Failure to Document Indication and Monitor Use of Psychotropic Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, psychoactive substance dependence, and Parkinson’s Disease was administered Ativan (Lorazepam), a psychotropic medication, without a clearly documented indication for its use. The resident was cognitively moderately impaired and dependent on all activities of daily living, with impairments in both upper and lower extremities. The care plan specified the use of anti-anxiety medication as needed for anxiety manifested by restlessness and agitation, but the specific manifestations were not consistently documented in the medication administration records or progress notes. Review of the Medication Administration Record showed that Ativan was given on multiple occasions for exhibiting a behavior, but the exact manifestation or behavior warranting the medication was not specified. The order summary for Ativan indicated it was to be given as needed for anxiety manifested by certain behaviors, but the manifestation was not clearly documented. Interviews with nursing staff confirmed that the order was incomplete, missing the required manifestation, and that monitoring of the resident’s behavior and side effects was not consistently documented as required by facility policy. Facility policies required that PRN psychotropic medication orders specify the condition for administration and that adequate indications for use be documented, including ongoing monitoring of mood, behavior, and side effects. The lack of clear documentation regarding the indication for Ativan administration and insufficient monitoring of the resident’s response and side effects led to the deficiency, as the facility failed to ensure that the use of psychotropic medication was appropriate and properly monitored for this resident.
Failure to Properly Handle and Dispose of Soiled Gowns
Penalty
Summary
Facility staff failed to ensure proper handling and disposal of soiled gowns, as evidenced by a soiled gown being observed on the floor of a resident room near the trash can, rather than in the designated soiled linen bins. During observation, a Certified Nursing Assistant (CNA) acknowledged that the gown may have fallen from a plastic bag and confirmed that all staff are expected to place soiled gowns in plastic bags and then into the appropriate barrel. The CNA also stated that housekeepers should be called to clean the area whenever soiled gowns or linens are found on the floor. Additionally, a Licensed Vocational Nurse (LVN) was observed leaving the resident room without picking up the soiled gown, and confirmed that staff are not supposed to leave dirty gowns or linens on the floor due to infection control concerns. The Director of Staff Development (DSD) stated that nurses receive regular in-service training on infection control and that dirty linens or gowns should not be left on the floor, but instead placed in a bag and then in the barrel. Review of the facility’s policy and procedure confirmed that soiled linen should be collected at the point of use, placed in a linen bag or lined receptacle, and not kept in resident rooms or bathrooms.
Failure to Accurately Assess and Supervise Resident at Risk for Elopement
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anxiety, depression, and paranoid schizophrenia eloped from the facility without staff knowledge or supervision. The facility failed to accurately assess the resident's risk for wandering and elopement, as the elopement risk assessment indicated the resident was a low risk, despite documentation of wandering behavior and a history of homelessness, nicotine dependence, and alcohol use. The care plan contained conflicting information regarding the resident's risk factors, and the assessment did not reflect the resident's actual behaviors and history, leading to inappropriate interventions and lack of adequate supervision. On the day of the incident, the resident was last seen on the patio by the receptionist, who did not have a clear line of sight to the front door due to the position of her computer. The receptionist reported that the resident may have exited the facility while she was occupied with other tasks, as a wheelchair was later found near the front door. The LVN on duty last saw the resident in his room, and when the physical therapist went to locate the resident for therapy, he was missing. Staff initiated a search and called a code white for a missing person after realizing the resident was gone. Interviews with facility staff, including the RN and DON, confirmed that the elopement risk assessment and care plan were inaccurate and inconsistent, resulting in a lack of appropriate supervision and interventions. The facility's policies required comprehensive and accurate assessments to inform person-centered care plans and adequate supervision for residents at risk of elopement, but these procedures were not followed, directly contributing to the resident's unsupervised exit from the facility.
Failure to Readmit Resident After Hospitalization Despite Available Beds
Penalty
Summary
The facility failed to ensure that a resident who was transferred to a General Acute Care Hospital (GACH) was readmitted to the facility after being cleared for discharge. The resident, who had diagnoses including cerebral infarction and atrial fibrillation and required moderate assistance with activities of daily living, was transferred to the hospital due to desaturation and altered mental status. Upon stabilization and clearance for discharge from the hospital, the facility denied the resident's readmission, despite having available beds and a policy stating that residents should be permitted to return upon discharge from acute care. Interviews with facility staff, including the Registered Nurse Supervisor, Admission Coordinator, Director of Nursing, and Administrator, confirmed that the resident's bed hold had expired, but there were open beds available and the resident should have been allowed to return. The Admission Coordinator and Administrator both cited the resident's outstanding share of cost as a possible reason for the denial, but acknowledged that inability to pay should not have prevented readmission. The Admission Coordinator admitted to not assisting the resident with her financial concerns or referring her to social services for help. The resident expressed significant emotional distress as a result of being denied readmission, describing feelings of sadness, anxiety, and fear about her future and her belongings left at the facility. The facility's actions resulted in the resident's temporary loss of residence and negative psychosocial outcomes, as evidenced by her vocalizations of depression and loss of trust in the facility staff.
Failure to Implement Infection Control Measures for Water Testing and Visitor PPE
Penalty
Summary
The facility failed to implement required infection control measures in two key areas. First, the facility did not conduct annual Legionella water testing as outlined in its own policies and procedures. Review of the Water Management Program Binder revealed no Legionella testing results for 2024, and the Infection Preventionist Nurse (IPN) was unsure about the annual testing requirement. The contracted testing company confirmed that a scheduled test was canceled by the previous administrator, and the Maintenance Supervisor stated that a risk assessment was performed instead, which he believed could not replace actual Legionella testing. The facility's policies specifically required annual CDC elite Legionella testing, and staff interviews confirmed that this was not completed as required. Second, the facility failed to ensure that visitors of a resident on Enhanced Barrier Precautions (EBP) wore appropriate personal protective equipment (PPE) during their visit. The resident in question had multiple diagnoses, including hemiplegia, hemiparesis, urinary tract infection, dysphagia, diabetes, hypertension, and severe sepsis, and was dependent on staff for daily activities. Observations showed that four visitors were in the resident's room without PPE, engaging in direct contact such as holding hands, hugging, and sitting on the resident's bed. Although the family member was aware of EBP and the location of PPE, staff did not enforce the use of PPE during the visit. Facility policies required staff to educate and remind visitors about EBP and PPE use, but this was not consistently implemented. Staff interviews confirmed the importance of enforcing EBP to prevent the transmission of pathogens, and the Infection Preventionist acknowledged that all staff were responsible for visitor education regarding infection control measures. The failure to follow these protocols resulted in compromised infection control practices within the facility.
Failure to Update and Implement Comprehensive Care Plans for Oral Hygiene and Dietary Changes
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies related to oral care, hygiene, and dietary needs. For one resident with multiple sclerosis, neuropathy, seizures, and functional quadriplegia, the care plan did not address oral care, hygiene, or the resident's refusal of these activities. Observations revealed food particles and debris in the resident's mouth, and interviews confirmed that oral care was not being provided daily. The resident was dependent on staff for all activities of daily living and had impaired cognitive skills, yet the care plan lacked specific interventions for oral hygiene and refusal of care. Another resident, diagnosed with metastatic breast cancer, seizures, urinary tract infection, and muscle weakness, experienced a change in condition that required a switch from a regular to a puree diet and the need for a one-on-one feeder. Despite these significant changes, the resident's care plan was not updated to reflect the new dietary requirements or the need for individualized feeding assistance. Observations confirmed that the resident was being fed by a certified nursing assistant and required extra time to swallow, but these interventions were not documented in the care plan. Interviews with nursing staff and the Director of Nursing confirmed that care plans should be updated to reflect changes in condition, refusals of care, and specific interventions such as oral hygiene and dietary modifications. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but these requirements were not met for the two residents in question.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for two Certified Nurse Assistants (CNAs), as evidenced by a review of their personnel files which showed no evaluations were conducted in the previous year. Interviews with the Director of Staff Development and the Director of Nursing confirmed that evaluations are required upon hire, after 90 days, and annually thereafter, but these were not performed as expected. The facility's own assessment tool also indicated that staff skills and competencies should be validated upon hire and regularly thereafter, in accordance with regulations, but this process was not followed for the two CNAs.
Medication Error Rate Exceeds Acceptable Threshold Due to Late and Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with six medication errors identified out of 34 opportunities, resulting in a 17.65% error rate. The errors affected two residents observed during medication administration. For one resident, a Licensed Vocational Nurse (LVN) administered only part of the scheduled 9:00 AM medications during the initial pass and returned later to give the remaining five medications, including magnesium oxide, aspirin, vitamin C, multivitamins, and gabapentin, after the acceptable administration window had passed. The LVN acknowledged that these medications were late and that this was due to splitting the medication pass, which was not her usual practice. Another error involved a different LVN administering the incorrect formulation of a cough medication to a resident with chronic obstructive pulmonary disease (COPD). The resident was prescribed guaifenesin 100 mg/5 ml oral liquid, but instead received Geri-Tussin DM, which contains a higher dose of guaifenesin and an additional active ingredient, dextromethorphan. The LVN admitted to not verifying the medication formulation against the physician's order and stated that she should have clarified the order with the physician before administration. The facility's policy on medication administration requires that medications be given as ordered by the physician and within 60 minutes of the scheduled time, unless otherwise specified. Both LVNs involved in the incidents acknowledged their errors and the importance of adhering to physician orders and facility policy to ensure safe medication administration.
Significant Medication Errors Due to Late Administration and Failure to Hold Antihypertensives
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors in multiple instances. In one case, a nurse administered gabapentin and other medications to a resident later than the physician-ordered time frame. The nurse split the medication pass, resulting in five medications, including gabapentin, being given after the acceptable window. The nurse acknowledged the error, stating that the medications were supposed to be administered by a certain time and that late administration could cause medical complications. In two other cases, the facility did not follow physician-ordered parameters for holding blood pressure medications. For one resident, amlodipine was administered on two occasions when the resident's systolic blood pressure was below the ordered threshold of 110 mmHg. The nurse confirmed that the medication should have been held according to the order and facility policy. Similarly, another resident received both lisinopril and amlodipine when their systolic blood pressure was below the hold parameter. The nurse involved acknowledged that administering these medications under such conditions could further lower blood pressure. The facility's policies required medications to be administered as ordered by the physician, including holding medications when vital signs were outside prescribed parameters. Staff interviews confirmed awareness of these requirements, but the documented medication administration records showed that these protocols were not followed, resulting in significant medication errors for the affected residents.
Deficient Food Storage, Sanitation, and Temperature Control in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen. Surveyors observed a large tray of previously cooked ham stored in the walk-in refrigerator past its use-by date. The Dietary Supervisor confirmed that the ham had exceeded its storage date and should have been discarded, acknowledging that old ham can cause illness. Facility policy and the FDA Food Code require proper labeling, dating, and timely use or disposal of refrigerated foods, which was not followed in this instance. Additional observations revealed that the kitchen stove and oven were dirty, with dried food debris, stains, and greasy residue present on the surfaces and knobs. The shelf under the food preparation counter was also found to have food crumbs and debris. The only can opener in the kitchen had a worn, nicked blade, making it difficult to clean and sanitize properly. The Dietary Supervisor and Cook both acknowledged these issues during interviews, and facility sanitation assessment reports had previously noted the need for improvement in these areas. During lunch service, texture-modified fish was held on the steam table at 125°F, below the required hot holding temperature of 135°F. The cook recorded this temperature as acceptable and did not reheat the food, despite facility policy and FDA Food Code requirements. Additionally, food contact surfaces were wiped with a towel stored in a sanitizer solution that was dirty and ineffective, as confirmed by a test strip. The cook admitted the solution was not effective and needed to be changed, contrary to facility policy requiring regular testing and changing of sanitizer solutions.
Failure of QAA/QAPI Committees to Oversee Repeat Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to provide effective oversight of the plan of correction for deficiencies identified during the previous recertification survey. Specifically, the committees did not actively manage ongoing systemic issues related to medication error rates of five percent or more, food and nutrition services, and the antibiotic stewardship program. These areas had been identified as deficient in the prior survey, but were no longer considered high-focus topics by the QAA committee, despite their continued relevance. During interviews and record reviews, the Administrator confirmed that these systemic issues were not currently being addressed by the QAA committee, even though they had been included in the QAPI plan following the previous survey. The facility's policy and procedure for the QAPI plan outlines the need for ongoing data monitoring, performance measurement, and prioritization of problems, but these processes were not being followed for the repeat deficiencies. As a result, all 84 residents were affected by the lack of oversight and continued deficiencies in these critical areas.
Failure to Implement Antibiotic Stewardship Program and Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for two residents, resulting in deficiencies related to the monitoring and documentation of antibiotic use. For one resident with a history of acute cystitis, peritoneal abscess, and bacteremia, there was no documented indication for the use of Bactrim, and an antibiotic time-out was not performed after the medication was started. The Infection Preventionist Nurse (IPN) was unable to determine the reason for the Bactrim prescription and found no supporting documentation in the physician or surgeon's notes. Additionally, there was no laboratory testing conducted to justify the initiation of Bactrim, and the medication order lacked an end date, contrary to facility policy and standard practice. For another resident with multiple myeloma and anemia, Bactrim was prescribed for prophylactic use without a care plan or documentation of monitoring for adverse reactions or side effects. The IPN acknowledged that the antibiotic time-out was completed only once, with no subsequent laboratory evaluation or assessment of the resident's status. Nursing progress notes did not include any information about monitoring for side effects or adverse reactions, and the resident's care plan did not address the ongoing use of Bactrim. Facility policy requires that all antibiotic prescriptions specify dose, duration, and indication, and that nursing staff conduct antibiotic time-outs within 48-72 hours of starting therapy. The policy also mandates monitoring for response to antibiotics and documentation of assessments. In both cases, these protocols were not followed, as evidenced by missing documentation, lack of laboratory testing, and absence of care planning and monitoring for adverse effects.
Call Light Not Accessible to Resident with Physical Impairments
Penalty
Summary
The facility failed to ensure that a resident with significant physical impairments had access to a call light within reach. The resident, who was admitted with diagnoses including nontraumatic intracerebral hemorrhage, hemiplegia, and hemiparesis, was observed in bed with the call light placed on the wall behind the headboard, out of reach. The resident confirmed that when the call light was not accessible, he would have to call out loudly for assistance if needed. Staff interviews corroborated the observation, with a CNA and LVN both acknowledging the importance of keeping the call light within reach for residents, especially in case of emergencies or when assistance is needed. A registered nurse further noted that lack of access to the call light could delay care, such as timely assistance with toileting, which could lead to adverse outcomes. Review of facility policy confirmed that staff are required to ensure call lights are accessible to residents while in bed.
Failure to Accurately Complete PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a required Level 1 Preadmission Screening and Resident Review (PASARR) was completed accurately for one resident. The resident was admitted with multiple mental health diagnoses, including depressive disorder, bipolar disorder, anxiety disorder, and mood affective disorder. The resident's history and physical indicated a lack of capacity to understand and make decisions, and the Minimum Data Set (MDS) assessment showed moderate cognitive impairment and significant assistance required for daily activities. The resident was also prescribed high-risk medications such as antipsychotics and antidepressants. Despite these documented mental health conditions, the PASARR Level 1 screening for the resident was marked as negative, indicating no serious mental illness and that a Level 2 screening was not required. The screening form specifically noted the absence of serious diagnosed mental disorders, which contradicted the resident's medical record and diagnoses. This inaccurate completion of the PASARR Level 1 screening prevented the initiation of a Level 2 PASARR evaluation, which is necessary for residents with serious mental illness to determine appropriate care and services. Interviews with facility staff, including Medical Records and the DON, confirmed that the PASARR process is intended to identify residents who require specialized mental health services prior to admission. Staff acknowledged that the Level 1 PASARR was not completed accurately for this resident and that a new screening should have been conducted. The facility's policy requires coordination with the PASARR program to ensure proper screening and referral for residents with mental disorders, but this process was not followed in this case.
Failure to Provide and Document Oral Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including multiple sclerosis, neuropathy, seizures, and functional quadriplegia, was observed to have poor oral hygiene. The resident was found with food particles on the lips and white and orange material on the teeth. The resident was assessed as being severely cognitively impaired and fully dependent on staff for all activities of daily living, including oral care. Despite this, there was no documentation in the nursing progress notes of oral care being provided or refused over a period of several months. Interviews with staff revealed that the facility's protocol required documentation of both the provision and refusal of oral care, with CNAs expected to notify LVNs and the Director of Staff Development if a resident refused care. However, both the LVN and DON confirmed that there was no documentation of oral care or refusals for this resident, indicating that the required care was not provided. The facility's policies also specified that residents unable to perform activities of daily living should receive necessary services to maintain personal and oral hygiene, which was not met in this case.
Resident Not Properly Positioned During Feeding
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dysphagia, gastro-esophageal reflux disease, and muscle weakness, who was dependent on staff for activities of daily living and required assistance with feeding, was not positioned appropriately during mealtime. The resident's care plan specified that the head of the bed should be maintained at 30-45 degrees upright during feeding. However, during an observation, a certified nursing assistant was seen feeding the resident while the resident was lying on their left side with the head of the bed at a low 20-degree angle. The CNA acknowledged that this was not a proper feeding position and that the resident should have been placed in an upright position of at least 60 degrees. Further interviews with nursing staff, including an LVN and the DON, confirmed that feeding a resident in a low side-lying position is not recommended, as it can cause swallowing difficulties and increase the risk of aspiration. The facility's policy and procedure on accidents and supervision also indicated that residents should receive adequate supervision and interventions to reduce hazards and risks. The failure to position the resident upright during feeding was inconsistent with the resident's care plan and facility policy, constituting a deficiency in providing a safe environment and adequate supervision to prevent accidents.
Failure to Follow Up on Pain Management for Resident with Medication Allergies
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was allergic to both Aspirin and Acetaminophen. Upon admission, the resident's records clearly indicated these allergies. Despite this, a Pain Management Doctor ordered Tylenol (Acetaminophen) for pain, which was not administered due to the known allergy. The nurse documented that the PMD was notified about the allergy, but there was no follow-up for three days to obtain an alternative pain medication. Facility policy required staff to follow up with the physician three times within 24 hours and, if no response was received, to contact the resident's primary doctor or the Medical Director. Interviews with staff confirmed that the required follow-up actions were not taken, and the resident's pain management needs were not addressed in a timely manner. The resident's family member reported that the resident experienced stomach pain and was told by the PMD that pain medication would be ordered if needed. The lack of follow-up resulted in the resident potentially experiencing untreated pain, as no alternative pain management was provided during the period in question.
Expired Asthma Inhaler Not Removed from Medication Cart
Penalty
Summary
A deficiency was identified when an expired fluticasone/salmeterol inhaler, prescribed for a resident with asthma, was found in the facility's middle medication cart. The inhaler had been opened and labeled with an open date, but was not removed from the cart after the one-month period recommended by the manufacturer. During an observation and interview, the LVN acknowledged that the inhaler had expired and should have been removed, but was unaware of the specific expiration timeframe after opening. The resident involved had a history of asthma and was admitted to the facility with this diagnosis. The facility's policy required medications to be stored according to manufacturer recommendations and for expired medications to be routinely identified and destroyed. However, the expired inhaler remained accessible in the medication cart, contrary to both manufacturer guidelines and facility policy.
Failure to Provide Appropriate Vegetarian and Texture-Modified Diet
Penalty
Summary
The facility failed to follow standardized recipes and provide appropriate menu options for a resident who required both a vegetarian and minced and moist diet. On the observed lunch service, the cook did not prepare a vegetarian protein alternative for the resident, instead serving steamed carrots as a replacement for fish. The carrots were chopped rather than prepared to the required minced and moist texture, and the resident's meal ticket clearly indicated the need for a vegetarian, minced and moist diet. During the meal, the resident did not consume the chopped carrots, and staff had to mash them further and mix with soup to make them edible. Further observations revealed that the dietary supervisor was unaware of the vegetarian menu requirements for that day and did not notice the improper texture of the carrots served. The following day, the resident was served minced and moist shrimp, which was not appropriate for a vegetarian diet, and the shrimp was noted to be too dry and not minced finely enough. The speech therapist assisting the resident expressed concerns about the food's moisture and texture, and noted the resident's increased risk for aspiration due to posture and swallowing difficulties. The resident's medical history included Parkinson's Disease, dysphagia, and abnormal posture, with documented risks for choking, aspiration, and weight loss. Facility policies required that menus be revised based on resident preferences and that texture-modified diets be prepared as prescribed, with minced and moist foods meeting specific consistency standards. These requirements were not met for the resident in question, as evidenced by the observations and interviews conducted during the survey.
Failure to Develop Resident-Centered Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to develop comprehensive and resident-centered care plans for two residents with pressure ulcers. Both residents had significant impairments: one was admitted with stage 4 pressure ulcers to the sacral region and right hip, and was documented as moderately cognitively impaired and dependent on staff for activities of daily living (ADLs). The other resident, diagnosed with Parkinson's disease, required substantial to maximum assistance with ADLs and had a pressure ulcer on the right buttock and deep tissue injuries to both heels. Despite these conditions, the care plans for both residents only included interventions such as encouraging the residents to frequently shift their weight and educating them or their representatives on skin care, which were not feasible given their dependence on staff for mobility. Interviews with facility staff confirmed that both residents were unable to reposition themselves without assistance, and that the care plans did not reflect the actual care needs of the residents. The treatment nurse acknowledged that the interventions listed were not appropriate for residents who could not reposition themselves, and that staff should have been directed to reposition the residents every two hours. The Director of Nursing also stated that care plans should be individualized and resident-centered, reflecting each resident's specific needs and problems. Review of the facility's policy confirmed that care plans are required to describe resident-specific interventions aligned with their needs and preferences.
Failure to Revise Care Plan After Pressure Ulcer Progression
Penalty
Summary
The facility failed to revise the care plan for a resident after their pressure ulcer progressed from stage 1 to stage 3. The resident, who had Parkinson's disease and required substantial assistance with activities of daily living, was initially documented as having a stage 1 pressure ulcer on the right buttock. Despite the ulcer worsening to stage 3, the care plan interventions remained unchanged, and no updates were made to reflect the new condition or necessary interventions. Interviews with the treatment nurse, Director of Staff Development, and Director of Nursing confirmed that the care plan should have been revised to include updated interventions such as frequent repositioning, a low air loss mattress, and new treatment orders. The facility's policy required the care plan to be reviewed and revised by the interdisciplinary team after significant changes, but this was not done following the progression of the resident's pressure ulcer.
Delayed Pressure Ulcer Assessment After Resident Readmission
Penalty
Summary
A deficiency occurred when a resident, who had been readmitted to the facility with diagnoses including Parkinson's disease and required substantial assistance with activities of daily living, did not receive a timely skin and wound assessment by the treatment nurse following readmission. The resident's records indicated the presence of deep tissue injuries on both heels and a stage one pressure ulcer on the buttocks. According to facility staff interviews, the expectation was that a treatment nurse would complete a skin and wound assessment as soon as possible upon admission or readmission, ideally the same day or the next day, due to the potential for rapid changes in skin condition. Despite these expectations and the facility's policy requiring prompt assessment and documentation of pressure injuries, the treatment nurse did not complete the required assessment until several days after the resident's readmission. This delay in assessment was confirmed through interviews with the treatment nurse, the Director of Staff Development, and the Director of Nursing, all of whom acknowledged the importance of timely wound assessments to ensure accurate documentation and appropriate care. The facility's policy also specified the use of the Braden Scale for risk assessment upon admission or readmission, which was not documented as completed in a timely manner for this resident.
Failure to Uphold Resident Rights in Lift Transition
Penalty
Summary
The facility failed to uphold the rights of two residents when it decided to remove the Sit-to-Stand (SS) lifts without adequately addressing their concerns. Resident 1, who was admitted with conditions such as left hemiplegia, diabetes mellitus, and chronic obesity, was informed of the removal of the SS lift through a notice. Despite having the capacity to understand and make decisions, Resident 1 expressed feelings of depression and anxiety due to the change, as documented in her care plan and social service progress notes. The facility's decision forced her to use a Hoyer lift, which she found uncomfortable and feared falling from, leading to a violation of her rights. Similarly, Resident 2, who had type 2 diabetes with diabetic retinopathy and major depressive disorder, was also affected by the removal of the SS lift. Despite being capable of understanding and making decisions, Resident 2 expressed concerns about the Hoyer lift due to her sensitive skin and existing pressure injuries. She felt that her rights were not being upheld as the facility did not provide an opportunity for residents to voice their concerns before the removal of the SS lift. Interviews with staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed that the facility did not allow residents to refuse the use of the Hoyer lift, which led to delays in care and increased anxiety among residents. The Administrator admitted that the facility failed to ensure that all affected residents were heard before making the decision, acknowledging that better communication could have prevented the anxiety and frustration experienced by the residents.
Failure to Prevent Pressure Ulcer Risk Due to Inadequate Transition Planning
Penalty
Summary
The facility failed to ensure proper care for a resident at risk for pressure injuries, resulting in the resident sitting in a wheelchair for four hours, causing discomfort and increased risk of skin breakdown and infection. The resident, who had a history of left hemiplegia, diabetes mellitus, and chronic obesity, was dependent on staff for various activities and was at risk for developing pressure ulcers. The resident had Moisture-Associated Skin Damage (MASD) in the right abdominal fold and was not repositioned frequently enough after the facility removed the Sit to Stand (SS) lift, which was previously used to assist the resident in transitioning from a seated to standing position. The facility's decision to remove the SS lifts and transition to Hoyer lifts without adequately planning for the increased staffing needs led to the deficiency. The resident expressed concerns about the removal of the SS lift, stating discomfort with the Hoyer lift and anxiety about prolonged sitting in the wheelchair. The facility's notice about the removal of the SS lifts did not offer residents a choice, and the resident was forced to use the Hoyer lift despite objections. The transition required four staff members to assist with the Hoyer lift, which was not anticipated by the facility, resulting in delays in care and the resident sitting in the wheelchair for an extended period. Interviews with the resident, a Certified Nurse Assistant (CNA), and the Director of Nursing (DON) confirmed the deficiency. The CNA and DON acknowledged that the transition to the Hoyer lift was not adequately planned, leading to the resident's prolonged sitting and increased risk of skin breakdown. The facility's policy on pressure injury prevention and management emphasized the commitment to preventing avoidable pressure injuries, but the lack of proper planning and execution in the transition process led to a failure in providing timely and appropriate care for the resident.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate fall prevention measures for a resident assessed at risk for falls, resulting in the resident sustaining a head injury. The resident, who had a history of getting out of bed unassisted, was not monitored with the increased frequency as outlined in their care plan. The care plan, dated 7/1/2024, specified that the frequency of monitoring rounds should be increased to reduce the risk of falls, but this was not adhered to by the nursing staff. The resident, who was admitted with diagnoses including dementia, difficulty walking, and muscle weakness, was found on the bathroom floor with a head injury after attempting to go to the bathroom unassisted. The resident's Minimum Data Set indicated severe cognitive impairment and a need for maximal assistance with toileting and hygiene. Despite these needs, the facility's staff did not follow the care plan's intervention of frequent visual checks every two hours, as evidenced by the resident being last checked at 2 p.m. and found on the floor at 2:45 p.m. Interviews with staff revealed a lack of awareness and communication regarding the specific monitoring needs of the resident. The Director of Nursing and other staff members were not aware of the resident's history of attempting to get out of bed unassisted, and there was no documentation of the monitoring checks. The facility's policy on fall prevention required increased frequency of rounds for at-risk residents, but this was not implemented, leading to the resident's fall and injury.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who had undergone a right total knee replacement and was experiencing severe pain. The resident, who had a history of right knee osteoarthritis and major depressive disorder, reported a pain level of eight out of ten but did not receive the prescribed Oxycodone-Acetaminophen in a timely manner. The resident's care plan included ensuring the availability of pain medication and providing reassurance to manage anxiety, but these interventions were not implemented effectively. The deficiency occurred because the keys to the medication cart were not properly endorsed to a licensed nurse during the shift change. The Registered Nurse Supervisor left the facility with the keys, preventing access to the medication cart and the Emergency Kit. As a result, the resident's pain was not addressed for over two hours, leading to increased pain and anxiety. The resident expressed frustration and anxiety, pacing the hallways and seeking assistance from staff, but was unable to receive the necessary medication until the keys were returned. Interviews with staff revealed that there was a lack of communication and coordination among the nursing staff. The Licensed Vocational Nurse on duty was not able to access the medication cart or the Emergency Kit due to the absence of the keys. The Director of Nursing stated that the staff should have contacted her or the physician to resolve the issue, but this was not done. The facility's policy on pain management emphasized the importance of timely and effective pain management, which was not adhered to in this case.
Failure to Conduct IDT Meeting for Resident's Hemodialysis Refusal
Penalty
Summary
The facility failed to ensure that an Interdisciplinary Team (IDT) Care Conference meeting was initiated for a resident who refused to attend scheduled hemodialysis (HD) sessions. The resident, who had intact cognitive skills and was capable of making decisions, missed HD on two occasions due to transportation issues. The ambulance company mistakenly went to the resident's home instead of the facility, causing delays. Despite these issues, no IDT meeting was held to discuss the resident's refusal of HD or to address the transportation problems. The resident's medical history included conditions such as diabetes mellitus, atrial fibrillation, chronic obstructive pulmonary disease, morbid obesity, end-stage renal disease, anemia, benign prostatic hyperplasia, and dependence on renal dialysis. The facility's policy stated that residents have the right to participate in the development and implementation of their person-centered plan of care. However, the Social Services Director acknowledged that no IDT meeting was conducted to involve the resident in discussing the plan of care or to find solutions to the transportation issues.
Failure to Aggressively Treat Skin Breakdown and Contact Dermatitis
Penalty
Summary
The facility failed to aggressively treat skin breakdown and prevent the progression of contact dermatitis for two residents, Resident 22 and Resident 40. For Resident 22, the facility did not implement the Documentation of Wound Treatments policy and procedure by failing to include the resident's response to the treatment ordered for contact dermatitis. Despite multiple evaluations and changes in treatment orders by the wound specialist, Resident 22 continued to experience intense itching and scratching, indicating that the treatments were not effective. The facility also delayed consulting a dermatologist, which resulted in a diagnosis of Prurigo Nodularis 72 days after the initial diagnosis of contact dermatitis. Resident 40 also experienced a generalized body rash that was not effectively treated. The facility did not reassess treatment interventions in a timely manner, and the resident continued to suffer from intense itching and scratching. Despite being seen by the wound specialist, no new treatment orders were provided, and the resident had not been seen by a dermatologist since January 2024. The facility's failure to consult a dermatologist and reassess treatment interventions contributed to the persistence of the resident's condition. The facility did not inspect all residents in a timely manner for possible contact and spread of skin rashes. The Director of Nurses (DON) acknowledged that several residents had rashes since January 2024, which was unusual. The DON expressed concern about the residents' prolonged discomfort and the potential for skin infections. The facility's failure to follow its policies and procedures for skin assessments and documentation of wound treatments contributed to the residents' ongoing suffering and the potential for further complications.
Failure to Document Medical Condition and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that mirtazapine, a psychotropic medication, was used for a documented medical condition in one resident. The resident, who was admitted with Alzheimer's disease, did not have a diagnosis of depression or major depressive disorder in her clinical records. Despite this, mirtazapine was prescribed for depression manifested by withdrawal from activities of interest, without any supporting documentation or care plans indicating depression as a diagnosis or targeted intervention for the medication's use. Additionally, the facility did not monitor or quantify the target behavior of withdrawal from activities of interest or adverse effects related to the use of mirtazapine. The resident's Medication Administration Record did not show any monitoring for adverse effects or documentation of the resident's behavior per shift. This lack of monitoring and documentation meant that the effectiveness and potential adverse effects of the medication were not being assessed, increasing the risk of harm to the resident. During an interview, the Director of Nursing acknowledged the failure to document a clear medical indication for the use of mirtazapine and the lack of resident-centered care plans. The DON also admitted that the facility did not monitor the resident's behaviors or adverse effects in a meaningful way, which would allow for periodic reassessment of the medication's benefits versus risks. This failure was in direct violation of the facility's policy on the use of psychotropic medications, which requires documented medical conditions and monitoring of the resident's response to the medication.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to ensure that its medication error rate was less than five percent, resulting in an overall medication error rate of 26.67%. This deficiency affected one resident, who experienced eight medication errors out of 30 total opportunities. The errors included omitted doses of Symbicort and Preservision AREDS2, and late administration of aspirin, lisinopril, gabapentin, vitamin C, zinc sulfate, and Eliquis. These errors were observed during a medication pass and confirmed through interviews and record reviews. The resident involved had a history of asthma and macular degeneration and was unable to make his own medical decisions. The errors were primarily due to the unavailability of certain medications in the medication cart and the high workload of the licensed vocational nurse (LVN) responsible for administering the medications. The LVN admitted to marking the Medication Administration Record (MAR) incorrectly, indicating that medications were administered when they were not. The Director of Nursing (DON) confirmed that the facility's policy requires medications to be administered within 60 minutes of the scheduled time and that any missing medications should be reported to the pharmacy, the resident's physician, and the DON. However, the LVN did not follow this protocol, leading to the medication errors. The facility's failure to administer medications as ordered increased the risk of medical complications for the resident.
Failure to Administer Symbicort Inhaler
Penalty
Summary
The facility failed to administer ten doses of Symbicort inhaler to a resident between 4/1/2024 and 4/10/2024, as per the physician's order. The resident, who was admitted with diagnoses including asthma and macular degeneration, was unable to make his own medical decisions. The Medication Administration Record (MAR) indicated that the Symbicort inhaler was scheduled to be given daily at 9:00 AM starting on 4/1/2024. However, the medication was not available in the facility, and the licensed vocational nurse (LVN) responsible for administering it did not follow up with the pharmacy or the physician to resolve the issue or order an alternative medication. During an observation on 4/10/2024, the LVN was seen preparing and administering other medications for the resident but did not administer the Symbicort inhaler. The LVN admitted that the Symbicort inhaler had never been received from the pharmacy due to a cost issue and that she had erroneously marked the MAR as if the medication had been administered. The LVN acknowledged that she marked the MAR in error due to her high workload and did not check which medications were actually administered. She also stated that if a medication is unavailable, it should not be marked as administered in the MAR, and the circumstances should be documented in the nurses' progress notes. The Director of Nursing (DON) confirmed that the LVN should have notified the pharmacy, the resident's physician, and the DON about the missing medication, as it would be treated as a medication error. The DON stated that none of the LVNs had contacted her about the missing medication for the resident. The facility's policy on medication administration requires that medications be administered as ordered by a physician and in accordance with professional standards of practice, and that the MAR should be signed only after the medication has been administered.
Expired and Improperly Stored Medications, Unsecured Medication at Bedside
Penalty
Summary
The facility failed to ensure that expired insulin pens and vials were removed from the medication cart, affecting multiple residents. Specifically, five expired insulin pens and one expired insulin vial were found in the Station 2 Medication Cart. These medications were labeled with open dates that indicated they had expired, yet they were still present in the cart. Licensed Vocational Nurse (LVN) 4 confirmed that the expired insulin could be ineffective at controlling blood sugar levels, potentially leading to medical complications requiring hospitalization for the affected residents. Additionally, the facility did not store unopened insulin pens and vials according to the manufacturer's requirements. During an inspection of the Middle Medication Cart, one unopened Novolin R pen, one unopened Humalog pen, and one unopened Lantus insulin vial were found stored at room temperature instead of in the refrigerator. LVN 1 acknowledged that these medications should have been stored in the refrigerator upon delivery from the pharmacy. The improper storage made it impossible to determine the expiration dates, posing a risk of using ineffective insulin for residents. Furthermore, the facility failed to secure a medication in a locked storage area for one resident by leaving Hydrocortisone cream at the resident's bedside unattended and without a physician's order. The resident stated that she kept the cream at her bedside for convenience, and the licensed nurses were aware of this. However, both LVN 4 and the Treatment Nurse confirmed that medication should not be left at the bedside without a physician's order and proper documentation in the care plan. The Director of Nurses (DON) reiterated that an interdisciplinary care team meeting is required to determine if a resident can safely self-administer medication, and it must be documented in the care plan.
Failure to Follow Menu and Portion Sizes for Mechanical Soft and Pureed Diets
Penalty
Summary
The facility failed to follow the lunch menu and portion sizes as written for residents on mechanical soft and pureed diets. Specifically, 18 residents on the mechanical soft diet received 3 ounces of ground roast beef instead of the prescribed 4 ounces, and seven residents on the pureed diet received 3 ounces of pureed roast beef instead of the prescribed 5 1/3 ounces. This discrepancy was observed during the tray line service for lunch, where the cook used a smaller scoop than indicated in the food portion and serving guide. The cook acknowledged the mistake and confirmed that they served less protein than required by the menu. The Registered Dietitian (RD) and Dietary Supervisor (DS) both confirmed that the cooks should follow the spreadsheet for serving sizes. The facility's policy on menu planning criteria, which was reviewed, indicated that the food and nutritional needs of residents should be planned to meet the U.S. dietary guidelines. The facility's recipe for pureed fish/meat/poultry also directed staff to refer to the spreadsheet for appropriate portion sizes. Despite these guidelines, the incorrect scoop sizes were used, leading to the deficiency in meal portions for the residents on mechanical soft and pureed diets.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to prepare pureed food by methods that conserved texture and appearance, resulting in a lumpy and chunky consistency that required chewing before swallowing. During an initial facility tour, complaints about food choices and preferences were identified. Observations in the kitchen revealed that the pureed lasagna was dry, firm, and not smooth, with small chunky pieces of pasta present. A taste test confirmed that the pureed lasagna required chewing and moving around in the mouth before swallowing. Cook1 acknowledged that the pureed lasagna was not smooth and stated that pasta and rice are hard to blend and require more liquid to achieve a smooth consistency. Cook1 also recognized that improperly pureed food could be a choking risk and subsequently re-blended the lasagna with added broth until smooth. The facility's recipe for pureed casseroles and the policy for pureed diets both indicated that pureed foods should be smooth, lump-free, and extremely thick. The policy emphasized that pureed foods are designed for individuals with severe chewing and swallowing problems and should eliminate the chewing phase. The failure to adhere to these guidelines placed seven residents on the pureed diet at risk for choking and meal dissatisfaction, potentially leading to decreased intake and unplanned weight loss.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices. Observations revealed that a large pan of previously prepared creamy salad dressing with an expired use-by date was stored in the walk-in refrigerator. Additionally, an open container of raw liquid eggs was stored together with ham sandwiches, and several items in the dry storage area, including powdered milk and raisin bran cereal, were expired. In the walk-in freezer, multiple food items were found without labels or dates, and some were uncovered and exposed to the freezer environment. The Dietary Supervisor acknowledged these issues and removed the expired and improperly stored items. In the dishwashing area, a staff member did not wash their hands before handling clean and sanitized dishes. The staff member was observed rinsing soiled dishes, dipping their hands in a bucket filled with sanitizer solution, and then proceeding to remove clean dishes without proper handwashing. The staff member admitted to not following proper handwashing procedures due to being in a hurry. The Dietary Supervisor confirmed that proper handwashing should be done with soap and water and that there should be two staff members assigned to the dishwashing area to prevent cross-contamination. Food brought to residents from outside the facility was also not properly managed. Observations in the resident refrigerator revealed expired items, including bread, coffee creamer, and cream, as well as undated muffins, raspberries, and a frozen dinner. The Activity Director, responsible for checking and discarding outdated food, acknowledged the oversight and removed the expired and undated items. The facility's policies on food storage and handling were not adhered to, leading to potential risks of harmful bacteria growth and cross-contamination.
Falsification of Medication Administration Record
Penalty
Summary
The facility failed to ensure the accuracy of the medication administration record (MAR) for a resident diagnosed with asthma and macular degeneration. The MAR falsely indicated that Symbicort, an inhaler for asthma, and Preservision AREDS2 vitamins, a supplement for eye health, were administered multiple times when these medications were not available in the facility. Specifically, Symbicort was documented as administered eight times, and Preservision AREDS2 vitamins were documented as administered 18 times, despite both medications being unavailable during the specified period. During an observation and interview, a licensed vocational nurse (LVN) admitted that the medications were not in the medication cart and had never been received from the pharmacy due to cost issues. The LVN acknowledged that she marked the MAR as if the medications were administered, citing a high workload and the practice of checking off the entire MAR at the end of the pass without verifying actual administration. This practice was confirmed during a review of the MAR and further interviews with the LVN and the Director of Nursing (DON). The DON stated that the LVN should have notified the pharmacy, the resident's physician, and the DON herself about the missing medications, treating it as a medication error. The facility's policies on medication administration and documentation were reviewed, indicating that medications should be administered as ordered and documented accurately. The failure to administer the medications and the falsification of the MAR were identified as deficiencies, with the potential for significant health risks to the resident.
Failure to Offer Pneumonia Vaccinations
Penalty
Summary
The facility failed to offer pneumonia vaccinations to two residents, Resident 8 and Resident 48, as required by their policy. Resident 8, who was admitted with diagnoses including dementia, COPD, and anemia, had not been offered the pneumonia vaccine since 2019 despite being severely cognitively impaired and unable to make decisions for activities of daily living. The Infection Preventionist (IP) admitted that the pneumonia vaccine was usually offered with the flu vaccine but was not offered to Resident 8 this year, and no follow-up was conducted to see if the resident wanted the vaccine. The Director of Nurses (DON) confirmed that the facility's policy required the vaccine to be offered three times and documented if refused, which was not done in this case. Similarly, Resident 48, who was admitted with diagnoses including schizophrenia, depression, and muscle weakness, had not been offered the pneumonia vaccine since 2021. The resident was also severely cognitively impaired and unable to make decisions for activities of daily living. The IP acknowledged that the pneumonia vaccine was not offered to Resident 48 this year and no follow-up was conducted. The DON reiterated that the facility's policy required the vaccine to be offered and documented if refused, which was not followed. The facility's policy indicated that residents should be offered the pneumococcal immunization unless medically contraindicated or already immunized, which was not adhered to in these cases.
Failure to Ensure Functioning Call Light for Resident
Penalty
Summary
The facility failed to ensure that a resident had a functioning call light, which is essential for obtaining care and services as needed. Resident 58, who was admitted with multiple diagnoses including epilepsy, gastrostomy, use of anticoagulants, Down syndrome, dysphagia, history of falling, and abnormalities of gait and mobility, was found to have a non-functional call light. The resident was cognitively severely impaired and dependent on all aspects of activities of daily living. During an interview, the resident's family mentioned that the call light button did not work. Observations confirmed that the call light was within reach but could not be pressed, and it did not light up outside the resident's room when tested by staff members, including a Licensed Vocational Nurse and the Activities Director. Maintenance staff acknowledged being notified but did not properly check the call light in the resident's room. The Director of Nursing confirmed that call lights are crucial for resident communication and that maintenance should be notified if a call light is not working. The facility's policy on promoting and maintaining resident dignity emphasizes the importance of providing equal access to quality care and ensuring that residents can call for assistance when needed. Despite this policy, the failure to ensure a functioning call light for Resident 58 compromised the resident's ability to obtain necessary care and services.
Failure to Notify Resident and Family of Room Change
Penalty
Summary
The facility staff failed to explain a room change and provide notice of the room change for Resident 337. Resident 337, who was admitted with diagnoses including cerebral infarction, encephalopathy, and hyperlipidemia, was moved from one room to another without prior notification or explanation. The resident, who lacked the capacity to understand and make decisions, was not informed about the move, which caused her distress and confusion. Her family was also not notified, leading to additional concern when they could not locate her upon visiting the facility. The resident reported feeling scared and not sleeping the night of the move, and she missed her dinner and breakfast trays during the transition. During an interview, the Social Service Director confirmed that there was no documentation explaining the reason for the room transfer to Resident 337 or her family. The facility's policy requires that residents and their families be notified and given an explanation for any room changes, but this procedure was not followed. The Social Service Director acknowledged that failing to provide notice and an explanation could lead to disappointment and is considered poor customer service. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity, including providing written notice before any room changes.
Failure to Create Resident-Centered Care Plan for Depression
Penalty
Summary
The facility failed to create a resident-centered care plan for a resident who was prescribed mirtazapine to treat depression manifested by withdrawal from activities of interest. The resident, diagnosed with Alzheimer's disease and lacking the capacity to make decisions, was admitted to the facility and prescribed mirtazapine via gastrostomy tube. However, the facility did not develop a care plan addressing the resident's depression or withdrawal behaviors, nor did it define goals of therapy for the use of mirtazapine. This omission was confirmed during an interview with the Director of Nursing (DON), who acknowledged the lack of a care plan and the importance of having one to manage problematic behaviors with both pharmacological and non-pharmacological interventions. The facility's policies on comprehensive care plans and behavioral health services emphasize the need for person-centered care plans that include measurable objectives and timeframes to meet residents' needs. Despite these policies, the facility did not create a care plan for the resident's depression and withdrawal behaviors, increasing the risk of adverse effects from the psychotropic medication. The DON admitted that the failure to create such a care plan could lead to adverse effects like sedation or drowsiness, potentially diminishing the resident's quality of life.
Failure to Ensure Proper Positioning and Safety Measures
Penalty
Summary
The facility failed to ensure that Resident 51 was properly positioned while eating lunch, which had the potential to cause aspiration and choking. Resident 51, who was admitted with diagnoses including orthostatic hypotension, bradycardia, and hyperlipidemia, required substantial assistance with eating. Despite an order for one-to-one feeding assistance, the resident was observed being fed in a low fowler's position, contrary to the facility's policy that mandates an upright position to prevent choking. Multiple staff members, including a CNA, LVN, RN, and the Director of Staff Development, confirmed that the resident should have been fed in an upright position to mitigate the risk of aspiration and choking. The facility also failed to conduct a thorough assessment to address the safety needs of Resident 36, who was legally blind and at high risk for falls. Resident 36 required moderate assistance for all activities of daily living, including toilet transfers. The resident's care plan did not include specific safety interventions for bowel and bladder elimination, which led to a fall incident. The resident's family member expressed concerns about the lack of a bedside commode and the promptness of staff response to call lights. The RN and MDS coordinator acknowledged that the care plan should have been updated to include safety interventions such as a bedside commode. Interviews with staff and review of the facility's policies revealed that the care plan for Resident 36 was not adequately updated to reflect the resident's high fall risk and specific needs during bowel and bladder elimination. The facility's policies on comprehensive care plans and fall prevention were not followed, resulting in the resident's fall. The Director of Staff Development confirmed that the lack of a bedside commode and delayed response to the call light contributed to the incident, which could have been prevented with proper interventions.
Failure to Accurately Account for Controlled Medication
Penalty
Summary
The facility failed to accurately account for one dose of a controlled medication, hydrocodone/apap 5/325 mg, for Resident 23. During an observation and interview with an LVN, it was discovered that the Controlled Drug Record indicated 29 doses left, while the medication card contained only 28 doses. The LVN admitted to administering the missing dose around 11 AM but failed to sign the Controlled Drug Record immediately due to being distracted by other tasks. This failure to document the administration of the controlled substance immediately after administration is against the facility's policy, which requires immediate reconciliation to prevent diversion and ensure proper medication administration. The facility's policy on Controlled Substance Administration & Accountability, last revised on 6/5/23, mandates that all controlled substances be accounted for on a designated usage form, with clear and legible documentation. Additionally, the Medication Administration policy dated 9/2/22 requires signing the narcotic book for controlled substances. The LVN's failure to adhere to these policies increased the risk of medication errors and potential diversion, compromising the safety and well-being of Resident 23.
Failure to Document Medication Regimen Review Upon Admission
Penalty
Summary
The facility failed to ensure a medication regimen review (MRR) was completed and documented upon admission for Resident 42. Resident 42 was admitted with diagnoses including polyarthritis and type 2 diabetes mellitus and had 29 active medication orders prescribed by his attending physician. However, there was no documentation in Resident 42's clinical record indicating that a pharmacist had performed a review of his entire medication profile since his admission. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged the absence of the required MRR documentation. The facility's policy on Quality Reporting: Drug Regimen Review mandates that a drug regimen review be documented upon a resident's admission and throughout their stay. Despite this policy, the facility did not obtain an initial MRR for Resident 42 or follow up with the pharmacy to identify any potential medication irregularities. This failure increased the risk of Resident 42 experiencing adverse effects related to his medication therapy, potentially leading to medical complications.
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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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