West Covina Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Covina, California.
- Location
- 850 S. Sunkist Ave., West Covina, California 91790
- CMS Provider Number
- 055992
- Inspections on file
- 62
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at West Covina Healthcare Center during CMS and state inspections, most recent first.
A resident with cerebral ischemia, type 2 DM, and moderately impaired cognition had a designated responsible party who requested the resident’s medical records through a legal services entity. The facility’s policy required resident access to records within 24 hours of request and photocopies within 48 hours, and staff reported an internal expectation to send records within seven working days. The MRD and DON stated that the chart was difficult to locate because it was stored in boxes, and the MRD had physical limitations, resulting in the records being sent after the required timeframe and violating the resident’s and responsible party’s right to timely access to medical records.
Two residents with cognitive impairments were involved in an unwitnessed physical altercation resulting in alleged facial injuries, but nursing staff did not initiate or document required neurological assessments as outlined in facility policy. Staff interviews and record reviews confirmed that neurological checks were not performed or recorded after the incident, despite clear protocols mandating such assessments following suspected head injuries.
A facility failed to report an alleged verbal abuse incident between two residents to the appropriate authorities within the required timeframe. A resident reported being called derogatory names by another resident, but the incident was not escalated to the Administrator or other required authorities as per the facility's policy. The Administrator was informed of the incident four days later by the resident's family member, highlighting a lapse in the facility's reporting procedures.
The facility failed to ensure call lights were within reach for two residents, compromising their ability to call for assistance. One resident, with impaired cognition and mobility issues, mistook the bed remote for the call light, while another resident, requiring substantial assistance, could not locate or reach the call light. This was against the facility's policy, which mandates call lights be accessible to residents.
The facility failed to ensure that residents' Advance Directives (AD) were discussed, documented, and included in their medical charts, affecting three residents with varying medical conditions and cognitive abilities. Despite facility policy, ADs were not completed or signed, and there was no evidence of assistance offered to formulate them, as confirmed by staff interviews.
The facility failed to provide daily care for the gastrostomy tube (GT) sites of two residents, as ordered by physicians. One resident's dressing was not changed daily, risking infection, while another's dressing was observed to be unclean and falling off. Staff confirmed the need for daily dressing changes to prevent bacterial growth.
The facility failed to attempt alternatives before installing grab bars for two residents, risking entrapment and injury. One resident with hemiplegia and depression had grab bars installed without documented alternative attempts. Another resident with diabetes and heart failure had grab bars posing an accident hazard, with no record of alternative measures tried. The facility's policy mandates attempting alternatives before bed rail use, which was not followed.
The facility failed to create individualized care plans for two residents, one with dementia and another on high-risk medications. The absence of a care plan for dementia in a resident requiring substantial assistance and the lack of a plan for black box medications in another resident with End Stage Renal Disease and Congestive Heart Failure were noted. This oversight could lead to inconsistent care, as highlighted by the facility's staff and policies.
A facility failed to coordinate care with a hospice provider for a resident with Alzheimer's and CHF by not ensuring scheduled visits by the Hospice RN were documented. Despite the hospice sign-in sheet indicating visits occurred, there was no evidence of visit notes. The DON admitted responsibility for monitoring these visits and ensuring documentation, as per facility policy.
A resident developed and experienced worsening of Stage 2 pressure ulcers due to the facility's failure to adhere to the care plan, which required repositioning every two hours. Despite the care plan's instructions, the resident was frequently observed lying on his back, and CNAs admitted to not repositioning the resident due to being busy with other duties.
A facility failed to adhere to professional standards for a resident receiving IV antibiotics by not labeling the PICC line dressing with the date it was applied. The resident, who had sepsis and hypertension, was observed with an unlabeled dressing, contrary to the facility's policy requiring dressing changes every seven days and proper labeling. This oversight was confirmed by an RN Supervisor, highlighting a lapse in infection control measures.
A resident with Alzheimer's and heart failure was prescribed two liters per minute of oxygen but was observed receiving four liters per minute. An LVN admitted to not checking the flow rate, contrary to the facility's policy, risking respiratory complications.
A facility failed to conduct a post-hemodialysis assessment for a resident with ESRD, as required by their policy. The resident's Dialysis Communication Record was incomplete, lacking documentation of the post-dialysis evaluation. The DON confirmed the necessity of this assessment to ensure the dialysis site was free from bleeding and vital signs were stable, highlighting a lapse in following established care protocols.
A resident with COPD and asthma had a dusty electric fan at their bedside, which had not been cleaned for an unknown period. Interviews with staff indicated that equipment should be kept clean to prevent infection, but the facility failed to adhere to its policy on maintaining a clean environment.
The facility failed to meet the required square footage for 13 rooms, each housing multiple residents. Despite the deficiency, residents could move freely, and staff had adequate space to provide care. The administrator planned to submit a waiver, noting that the rooms accommodated necessary equipment and did not compromise resident safety. Residents did not express concerns about room size.
A resident with heart disease and dementia was observed with cheek discoloration, but the facility failed to document this change, notify the physician, or develop a care plan. Despite staff awareness, the necessary procedures were not followed, risking delayed care.
A resident with limited mobility and unable to self-administer medications had several medications stored at their bedside, contrary to the facility's policies. Interviews confirmed the resident's preference for bedside storage, but the facility's procedures required medications to be stored in locked compartments. This posed a risk of unauthorized access.
Two residents in the facility were unable to reach their call lights, potentially delaying care. One resident, with a fracture and muscle weakness, was found with the call light hanging off the bed, while another resident, with a stroke and epilepsy, reported the call light was often on the floor. Both residents were dependent on staff for assistance, and the facility's policy required call lights to be accessible, which was not followed.
The facility failed to develop and implement a person-centered care plan for a resident using an antipsychotic medication. The resident, who had diagnoses including heart disease, heart failure, and dementia, had physician orders for Seroquel but lacked a care plan to address its use, side effects, and effectiveness. The Assistant Director of Nursing confirmed the oversight, which was against the facility's policy for comprehensive care plans.
The facility failed to follow its policy for antipsychotic medication use by not attempting non-pharmacological interventions or conducting a psychiatric evaluation before prescribing and increasing the dosage of Seroquel for a resident with dementia and hallucinations.
A resident experienced severe adverse reactions and was hospitalized after an LVN administered Narcan nasal spray instead of Flonase. The LVN failed to follow the facility's policy of checking the medication label three times, leading to the error.
A resident experienced severe adverse effects and required hospitalization after an LVN administered the incorrect medication due to not checking the medication label. The LVN had not completed the required medication competency assessments, and the facility failed to adhere to its policies on competent staffing and medication management.
A resident experienced severe adverse reactions after an LVN mistakenly administered Narcan instead of Flonase and failed to document the error in the MAR. The resident, with a history of asthma and chronic pain managed with opioids, was transferred to a hospital for treatment. Interviews revealed the LVN did not verify the medication label and did not document the administration accurately, contrary to facility policy.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to follow its policy and procedure titled "Release of Information" for one sampled resident, resulting in the resident’s responsible party not receiving timely access to the resident’s medical records. The resident had been re-admitted with diagnoses including cerebral ischemia and type 2 DM, had moderately impaired cognition per the MDS, and was later discharged and subsequently expired. The admission record identified the resident’s daughter as the responsible party. A written request for release of the resident’s medical records was submitted by a legal services entity and was documented as received by the facility. The facility’s policy stated that a resident may have access to records within 24 hours of a written or oral request and may obtain photocopies with at least 48 hours’ advance notice, excluding weekends and holidays. The Medical Records Director acknowledged that the request from the legal services entity was received and that the facility’s policy required records to be sent within seven working days, but stated that the records were not sent within that timeframe. The Medical Records Director reported difficulty retrieving the resident’s records because they were stored in boxes in the back of the facility and the director had physical limitations. The Director of Nursing confirmed that the facility could not easily locate the resident’s chart and that the records were released only after the chart was found. Both the Medical Records Director and the Director of Nursing stated that it was the right of the resident or responsible party to request and receive the resident’s medical records in a timely manner, and that the records could be needed for legal purposes and, if the resident were alive, for continuity of care.
Failure to Initiate Neurological Assessments After Unwitnessed Resident Altercation
Penalty
Summary
The facility failed to initiate neurological assessments for two residents following an unwitnessed resident-to-resident physical altercation involving alleged head injuries. Both residents had cognitive impairments and complex medical histories, including dementia and encephalopathy. After the incident, one resident was observed crying and covering a reddened left eye, while the other was noted to be in emotional distress. Both residents reported being struck in the face with a sandal during the altercation, but no neurological assessments were performed or documented for either individual. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy required immediate neurological assessments for any unwitnessed head or facial injury, regardless of visible trauma. The staff acknowledged that neurological checks should have been initiated and documented according to the facility's protocols, which specify frequent monitoring intervals and comprehensive documentation in the medical record. However, record reviews revealed that no such assessments were conducted or recorded for either resident following the incident. The facility's own policies, including the Neurological Assessment and Fall Management Program, outlined the necessity and frequency of neurological checks after suspected head injuries. Despite these clear guidelines, the required assessments were not performed, and the absence of documentation was confirmed through both record review and staff interviews. This failure to follow established procedures constituted a deficiency in the standard of care provided to the residents involved in the altercation.
Failure to Report Alleged Verbal Abuse in a Timely Manner
Penalty
Summary
The facility failed to adhere to its policy and procedure for abuse investigation and reporting by not reporting an alleged verbal abuse incident involving two residents to the appropriate authorities within the required timeframe. Resident 1, who has the capacity to understand and make decisions, reported that Resident 2 called them derogatory names in Spanish at the doorway of their room. This incident was reported by a Certified Nurse Assistant (CNA) to a Licensed Vocational Nurse (LVN), but it was not escalated to the Administrator (ADM) or other required authorities as per the facility's policy. The ADM was only made aware of the incident four days later by Resident 1's family member. Interviews with staff, including a Registered Nurse (RN) and the Assistant Director of Nursing (ADON), confirmed that the incident should have been reported immediately to the ADM, the Ombudsman, the California Department of Public Health (CDPH), and local law enforcement. The failure to report the incident promptly had the potential to subject Resident 1 to further abuse and compromised the safety of the residents, as the facility did not implement necessary interventions to prevent recurrence.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents by not ensuring their call lights were within reach and appropriate to their physical abilities. Resident 29, who was admitted with peripheral vascular disease and osteoarthritis, had moderately impaired cognition and required assistance with various activities. During an observation, it was noted that Resident 29 was unable to reach the call light, mistaking the bed remote control for it. The call light was placed on the upper part of the bed, out of reach, contrary to the care plan that required it to be within reach for safety. Similarly, Resident 80, who had hypertension and lack of coordination, required substantial assistance for toilet hygiene and transfers. During an observation, Resident 80 was unable to locate or reach the call light, which was coiled on the wall behind the bed. This placement prevented the resident from calling for help, as confirmed by a treatment nurse. The facility's policy required call lights to be within reach, but this was not adhered to, potentially delaying necessary care for the residents.
Failure to Document and Discuss Advance Directives
Penalty
Summary
The facility failed to ensure that the residents' Advance Directives (AD) were discussed, documented, and included in their medical charts, as per the facility's policy. This deficiency was identified for three residents, each with varying medical conditions and cognitive abilities. Resident 12, who had intact cognition and required assistance with daily activities, did not have an AD documented, and there was no evidence that assistance was offered or declined to formulate one. The admission coordinator confirmed that an AD should be completed upon each admission to determine the resident's preferences for end-of-life care. Resident 54, diagnosed with diabetes mellitus and dementia, was found to have severely impaired cognition and was dependent on assistance for most activities. Despite this, the resident's AD acknowledgment form was not signed by the conservator since admission, indicating a lack of compliance with the facility's policy that requires the AD to be filled out and signed with each admission. The Director of Nursing reiterated the importance of having an AD completed to guide the care and treatment preferences of the resident. Resident 78, who had impaired cognition and was dependent on assistance for daily activities, also lacked documentation of an AD. The Social Service Director stated that the facility relied on the POLST form to identify if a resident had an AD, but there was no documentation for Resident 78. The facility's policy requires the social services director to inquire about the existence of any written advance directives during the initial assessment, which was not adhered to in this case.
Failure to Provide Daily GT Site Care
Penalty
Summary
The facility failed to provide necessary care and services for the gastrostomy tube (GT) sites of two residents, as ordered by the physician and indicated in their care plans. Resident 45, who was admitted with diagnoses including dementia and required a feeding tube for nutrition, had a physician's order for daily cleansing and dressing of the GT site. However, the Treatment Administration Record (TAR) showed that the dressing was only changed on two specific dates, and an observation revealed that the dressing was not changed daily as required. The Infection Preventionist Nurse confirmed that the dressing should be changed daily to prevent infection. Similarly, Resident 54, who had diagnoses including diabetes mellitus and dementia, also had a physician's order for daily cleansing and dressing of the GT site. The TAR indicated that the dressing was changed on two specific dates, but an observation showed that the dressing was not clean and was falling off. The Certified Nurse Assistants and the Treatment Nurse confirmed that the dressing should be changed daily, including weekends, to prevent bacterial growth. The Director of Nursing also stated that the GT site should be checked daily for signs of infection and the dressing changed as ordered.
Failure to Attempt Alternatives Before Bed Rail Installation
Penalty
Summary
The facility failed to attempt the use of appropriate alternatives to grab bars before their installation for two residents, placing them at risk for entrapment and injury. Resident 35, who was admitted with conditions including hemiplegia, hemiparesis, and depression, was observed with grab bars on both sides of the bed without documented evidence of alternative measures being attempted. The Director of Nursing (DON) confirmed that no less restrictive alternatives were tried before the installation of the grab bars, which is against the facility's policy. Similarly, Resident 14, who was readmitted with diabetes mellitus and heart failure, was found with grab bars on the bed frame, which he did not use and was unaware of their purpose. The DON acknowledged that the grab bars posed an accident hazard and that the resident's medical record lacked documentation of attempts to use alternatives before the grab bars were applied. The facility's policy requires that alternatives be attempted and evaluated before the use of bed rails, which was not adhered to in these cases.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop specific and individualized person-centered care plans for two residents, leading to potential inconsistencies in care. Resident 45, who was admitted with dementia, anxiety, and depression, did not have a care plan addressing dementia despite having severely impaired cognition and requiring substantial assistance with daily activities. The Registered Nurse Supervisor acknowledged the absence of a care plan for dementia and emphasized the need for one to monitor the effectiveness of interventions. The Director of Nursing confirmed that care plans should be developed upon admission and updated as needed. Similarly, Resident 55, diagnosed with End Stage Renal Disease and Congestive Heart Failure, was prescribed high-risk medications with black box warnings, including Furosemide and Tylenol with Codeine #3. However, the care plan did not address these medications, which are crucial for monitoring potential side effects and ensuring proper interventions. The Registered Nurse Supervisor and the Director of Staff Development both highlighted the necessity of care plans for such medications to guide staff in providing appropriate care. The facility's policy on comprehensive person-centered care plans, revised in March 2023, mandates the development of care plans within seven days of the MDS assessment and no more than 21 days after admission. These care plans should include measurable objectives and timetables to meet residents' needs and reflect recognized standards of practice. The lack of care plans for Residents 45 and 55 indicates a failure to adhere to these policies, potentially impacting the residents' well-being.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to coordinate care with a hospice provider for a resident, identified as Resident 34, by not ensuring that the Hospice Registered Nurse (HRN) visited the resident on three scheduled dates. This deficiency was identified through observation, interview, and record review. Resident 34 was readmitted to the facility with diagnoses including Alzheimer's disease and congestive heart failure (CHF), and had an order for hospice care due to CHF. Despite the hospice sign-in sheet indicating that the HRN visited on the scheduled dates, there was no documented evidence of visit notes for these dates. The Director of Nursing (DON) acknowledged the lack of documentation and stated that it was their responsibility to monitor and audit the scheduled visits of hospice staff to ensure that visit notes were completed. The facility's policy and procedures designated the DON to coordinate care provided by hospice staff to residents. The absence of documented visit notes meant that the assessed care needs of Resident 34 were not recorded, and collaboration with facility staff regarding hospice services was not documented.
Failure to Reposition Resident Leads to Worsening Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care to prevent and manage pressure ulcers for a resident, identified as Resident 14. Upon readmission to the facility, Resident 14 did not have any pressure ulcers. However, a subsequent assessment revealed the development of Stage 2 pressure ulcers on the left buttock, which initially healed but later reopened, along with a new ulcer on the right buttock. The care plan for Resident 14 specified the need for repositioning every two hours to alleviate pressure on the ulcers, a critical step in promoting healing and preventing further deterioration. Observations and interviews conducted over several days revealed that Resident 14 was consistently found lying on his back, contrary to the care plan's instructions. Certified Nursing Assistants (CNAs) acknowledged the failure to reposition the resident as required, citing workload and time constraints as reasons for the oversight. This lack of adherence to the care plan resulted in the worsening of the pressure ulcers, as evidenced by the increase in size and redness of the wounds upon subsequent examination.
Failure to Label PICC Line Dressing
Penalty
Summary
The facility failed to provide care and service for a resident receiving parenteral antibiotics consistent with professional standards of practice. The deficiency was identified when the PICC line dressing for a resident was observed without a label indicating the date it was applied. This oversight was noted during an observation in the resident's room, where the resident was sitting in a wheelchair with a PICC line at the right upper arm covered by dressing gauze. The absence of a date label on the dressing was confirmed during an interview with the Registered Nurse Supervisor, who acknowledged that the dressing should be changed and labeled with the date to ensure timely dressing changes and infection control. The resident involved had been admitted with diagnoses including sepsis and hypertension and was receiving daily intravenous Cefazolin Sodium due to sepsis. The facility's policy required that the PICC line dressing be changed every seven days or as needed when soiled, and that the dressing be labeled with the date, time, and nurse's initials. The failure to label the dressing as per the facility's policy and procedure had the potential to result in infection and worsen the resident's health condition.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide necessary care and services for a resident on oxygen therapy by not adhering to the physician's order. The resident, who was readmitted with diagnoses including Alzheimer's disease and heart failure, was prescribed two liters per minute of oxygen through a nasal cannula continuously for shortness of breath. However, observations revealed that the resident was receiving four liters per minute of oxygen, which was not in accordance with the physician's order. Licensed Vocational Nurse 4 admitted to forgetting to check the oxygen flow rate during rounds, resulting in the resident receiving excessive oxygen. This oversight was contrary to the facility's policy and procedure for oxygen administration, which mandates that oxygen therapy be administered as ordered by the physician. The failure to follow the prescribed oxygen flow rate placed the resident at risk for respiratory complications due to potential oxygen toxicity.
Failure to Perform Post-Dialysis Assessment
Penalty
Summary
The facility failed to perform a post-hemodialysis assessment for a resident, identified as Resident 186, who required dialysis care. Resident 186 was admitted with diagnoses including End Stage Renal Disease (ESRD) and hypotension, necessitating regular hemodialysis treatments. A review of the resident's Dialysis Communication Record (DCR) dated 9/30/2024 revealed that the post-dialysis assessment section was left blank, indicating that the necessary evaluation was not conducted upon the resident's return to the facility. During an interview, the Director of Nursing (DON) confirmed that the DCR should be completed immediately after the resident's return to ensure the dialysis access site was free from bleeding and that the resident's vital signs were stable. The facility's policy on the care of residents with ESRD emphasized the importance of staff being trained to perform assessments before and after dialysis sessions. The lack of documentation and assessment posed a potential risk for complications related to the hemodialysis site for Resident 186.
Failure to Maintain Cleanliness of Resident's Electric Fan
Penalty
Summary
The facility failed to maintain an electric fan in a safe and sanitary condition for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and asthma. The resident, who required substantial assistance with daily activities, had a dusty electric fan at their bedside. During an observation and interview, the resident confirmed the fan blades were dusty and could not recall the last time it was cleaned. Interviews with housekeeping staff and the maintenance supervisor revealed that equipment inside residents' rooms should be kept clean to prevent infection and maintain a comfortable environment. The facility's policy on maintaining a homelike environment emphasized the importance of a clean, sanitary, and orderly setting. However, the dusty fan in the resident's room indicated a lapse in adhering to these standards.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 out of 38 rooms met the required square footage of 80 square feet per resident in multiple resident rooms. During an observation, it was noted that Rooms 14, 15, 16, 17, 18, 19, 27, 28, 29, 36, 37, 38, and 39 did not meet this requirement. Despite this, residents were able to ambulate freely and nursing staff had sufficient space to provide care with dignity and privacy. The rooms contained necessary furniture and medical equipment, and there was space for mobility and movement of ambulatory residents. The facility's administrator acknowledged the deficiency and indicated that a room waiver would be submitted for these rooms. The waiver request stated that there was ample room for wheelchairs and other medical equipment, and that the health and safety of residents were not compromised. The waiver detailed that the rooms were in accordance with the special needs of the residents and did not adversely affect their health and safety. However, the square footage for these 3-bed rooms was below the minimum requirement of 240 square feet, with each room ranging from 225.50 to 234.89 square feet. Residents interviewed did not express concerns about the size of their rooms.
Failure to Document and Address Change in Resident's Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident by not assessing, monitoring, and documenting a change in the resident's condition, specifically a discoloration on the left cheek. The resident, who was admitted with diagnoses including atherosclerotic heart disease, heart failure, and dementia, was observed with purple discoloration on the cheek. Despite this observation, there was no documentation of a change of condition report or a care plan addressing the discoloration. A Certified Nursing Assistant reported the discoloration to an LVN, who acknowledged the report but did not document it or notify the physician. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed that the change of condition should have been reported and documented promptly. The facility's policies and procedures require notifying the physician of changes in a resident's condition and developing care plans based on comprehensive assessments. The failure to adhere to these procedures resulted in the resident's condition not being monitored, which could potentially delay necessary care and services.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications for one resident, as per the facility's policies and procedures. The resident, who was admitted with diagnoses of hypothyroidism, essential hypertension, and type 2 diabetes mellitus, required substantial assistance with daily activities and was unable to self-administer medications. Despite this, several medications, including Laxaclear, Senokot, vitamin C tablets, and MiraFIBER gummies, were found at the resident's bedside during an observation. Interviews with the Infection Preventionist Nurse and the Administrator confirmed that the resident preferred having medications at the bedside, but was unable to self-administer them due to limited mobility. The facility's policies indicated that medications not authorized for self-administration should be returned to the nurse in charge, and all medications should be stored in locked compartments. The presence of medications at the resident's bedside posed a risk of access by other residents or unauthorized persons.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a potential delay in care. Resident 2, who was admitted with a fracture of the right femur, muscle weakness, and dysphagia, was observed lying in bed unable to reach the call light, which was hanging off the bed. The resident expressed hunger and was dependent on staff for various activities, including toileting hygiene and personal hygiene. A Licensed Vocational Nurse (LVN) adjusted the call light to be within reach, acknowledging that Resident 2 usually used the call light for assistance. Similarly, Resident 3, admitted with cerebral infarction, epilepsy, and dysphagia, reported that the call light was often not within reach, sometimes found on the floor. This resident was dependent on staff for toileting hygiene and showering. During an interview, Resident 3 stated that they had to shout for assistance when the call light was unreachable. The facility's policy indicated that call lights should be accessible to residents from their bed, toilet, shower, or floor, but this was not adhered to in these instances.
Failure to Implement Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for the use of an antipsychotic medication for one of the residents. The resident was admitted with diagnoses including atherosclerotic heart disease, heart failure, and dementia. The resident's Minimum Data Set indicated that the resident was understood by others and had the ability to understand others, and also had hallucinations. The resident had physician orders for Seroquel, an antipsychotic medication, but there was no care plan in place to address the use of this medication, including how to provide care, monitor side effects, and assess the medication's effectiveness. During an interview, the Assistant Director of Nursing confirmed that the resident should have had a care plan for the use of the antipsychotic medication. The facility's policy and procedure for comprehensive, person-centered care plans, which was revised in March 2022, indicated that such care plans should include measurable objectives and timeframes to meet the resident's needs. However, this was not implemented for the resident in question, leading to the deficiency noted in the report.
Failure to Follow Antipsychotic Medication Policy
Penalty
Summary
The facility failed to follow its policy and procedure for antipsychotic medication use for one resident. Specifically, the facility did not attempt non-pharmacological interventions before starting the resident on Seroquel, an antipsychotic medication. Additionally, the facility did not conduct a psychiatric evaluation before initiating or increasing the dosage of Seroquel. The resident was admitted with diagnoses including atherosclerotic heart disease, heart failure, and dementia, and exhibited behaviors such as hallucinations. Despite these symptoms, there was no documentation of non-pharmacological interventions or a psychiatric evaluation before the medication was prescribed and increased. The Assistant Director of Nursing confirmed that a psychiatric evaluation should have been conducted and that non-pharmacological interventions should have been documented. The facility's policy required the attending physician and staff to gather and document information about the resident's behavior, mood, function, and medical condition, and to attempt non-pharmacological interventions unless contraindicated. However, these steps were not followed, leading to the potential use of unnecessary medication for the resident.
Failure to Ensure Resident was Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, a Licensed Vocational Nurse (LVN) administered Narcan nasal spray instead of Flonase nasal spray to a resident. This error occurred because the LVN did not check the medication label three times as required by the facility's policy and procedure for administering medications. The resident experienced severe adverse reactions, including chest pain, a burning sensation, and feelings of impending death, and was subsequently transferred to a hospital for treatment of acute opioid withdrawal induced by the accidental Narcan administration. The resident had a history of asthma, allergic rhinitis, and chronic pain managed with Percocet and occasionally Morphine. The resident's physician had prescribed Flonase for nasal congestion and Narcan for emergency use in case of opioid overdose. On the day of the incident, the LVN retrieved a box labeled with the resident's name but did not verify the medication inside. Despite the resident's protest that the medication did not look familiar, the LVN insisted it was correct and administered it. Immediately after administration, the resident experienced severe symptoms and was transferred to the hospital. Interviews with the LVN, the Pharmacist Consultant, and the Director of Nursing revealed that the LVN did not follow the five rights of medication administration, which include verifying the right medication, dose, time, route, and patient. The facility's policy and procedure for administering medications also emphasized the importance of checking the medication label three times to prevent errors. The LVN admitted to not following these protocols, which led to the medication error and the resident's subsequent adverse reaction.
Medication Error Due to Inadequate Staff Competency
Penalty
Summary
The facility failed to ensure that all nursing staff had the appropriate skills and competencies necessary to provide nursing care safely, resulting in a medication error that caused significant harm to a resident. Licensed Vocational Nurse (LVN) 1 administered the incorrect medication to a resident, leading to the resident experiencing severe adverse effects and requiring hospitalization. The error occurred because LVN 1 did not check the medication label before administration, mistakenly giving Narcan instead of the prescribed Flonase nasal spray. The resident, who had intact cognition and required supervision for various activities, was admitted with diagnoses including asthma, allergic rhinitis, and phantom limb syndrome with pain. The resident had a physician's order for Flonase nasal spray and Narcan nasal liquid for opioid overdose. On the day of the incident, LVN 1 administered Narcan instead of Flonase, causing the resident to experience chest pain, a burning sensation, and a feeling of impending death. The resident was subsequently transferred to a general acute care hospital for treatment of acute opioid withdrawal induced by the accidental Narcan administration. Interviews and record reviews revealed that LVN 1 did not follow the facility's policy and procedure for medication administration, which includes checking the medication label and ensuring the five rights of medication administration. Additionally, LVN 1 had not completed the required medication competency assessments before administering medications independently. The Director of Staffing Development and the Director of Nursing confirmed that the facility did not adhere to its policies on competent staffing and medication management, which contributed to the medication error and subsequent harm to the resident.
Failure to Document Medication Administration Accurately
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for a resident by not ensuring that an LVN documented the administration of Narcan nasal liquid instead of fluticasone furoate suspension. The incident occurred when the LVN administered Narcan to the resident, who immediately experienced severe adverse reactions, including chest pain, a burning sensation, and acute withdrawal symptoms. The resident was subsequently transferred to an emergency department for treatment, where it was confirmed that Narcan had been administered instead of the prescribed Flonase nasal spray. The resident, who had a history of asthma, allergic rhinitis, and chronic pain managed with opioids, was admitted to the facility with specific medication orders, including Flonase for nasal congestion and Narcan for opioid overdose. On the day of the incident, the LVN mistakenly administered Narcan, believing it to be Flonase, and failed to document this administration in the Medication Administration Record (MAR). The resident's immediate adverse reactions led to an emergency transfer to a hospital, where the error was identified and treated. Interviews with the resident, the LVN, and the Director of Nursing (DON) revealed that the LVN did not verify the medication label before administration and did not document the error in the MAR. The facility's policy required accurate documentation of all administered medications to ensure safety and communication among the care team. The failure to document the administration of Narcan accurately could lead to further medication errors and adverse effects, as noted by the DON.
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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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