West Valley Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in West Hills, California.
- Location
- 7057 Shoup Ave, West Hills, California 91307
- CMS Provider Number
- 055443
- Inspections on file
- 65
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 57
Citation history
Health deficiencies cited at West Valley Post Acute during CMS and state inspections, most recent first.
A resident with DM and neurologic deficits had a physician order for blood glucose monitoring before meals and at bedtime, with instructions to notify the physician for values below 70 mg/dl or above 300 mg/dl. An LVN documented a blood glucose of 335 mg/dl but did not notify the physician, later stating they became busy and failed to make the call. The DON confirmed there was no documentation of physician notification or nursing interventions for hyperglycemia, despite facility policy requiring prompt notification and documentation of changes in condition.
A resident with multiple serious conditions was admitted and prescribed several essential medications, which were not available for administration as ordered. Nursing staff documented the issue and contacted the pharmacy, but did not notify the physician about the missed doses, contrary to facility policy requiring prompt physician notification when medications are unavailable.
Two residents with cognitive and behavioral challenges were involved in a physical altercation after a dispute over television use, resulting in injuries to both. The facility did not implement interventions or care planning to address known behavioral triggers and roommate incompatibility, failing to follow its abuse prevention policy and leaving both residents unprotected from physical abuse.
A facility did not create a comprehensive care plan to address a resident's known behavioral triggers, such as sensitivity to noise and roommates' televisions, despite a history of severe cognitive impairment and psychosis. This omission led to a physical altercation between two residents, resulting in injuries, as no specific interventions were in place to prevent or manage the resident's behavioral outbursts.
Staff failed to provide privacy during indwelling urinary catheter care for two residents, leaving them exposed to the hallway or others during personal care. Both a CNA and an LVN admitted to not closing privacy curtains before care, despite facility policy and DON statements emphasizing the importance of resident dignity and privacy.
Residents were not given easy access to view survey results or to communicate with advocate agencies, as required. This deficiency was identified through observations that the necessary information was not made available to residents.
The facility did not keep copies of advance directives in the medical records for two residents with complex medical conditions, despite documentation in their POLST forms indicating such directives existed. During record reviews, staff were unable to locate the required documents, contrary to facility policy that mandates advance directives be readily accessible in the medical chart.
Staff failed to properly dispose of documents containing PHI, such as meal tickets with residents' names, room numbers, diet orders, and allergies, by discarding them in regular trash instead of a confidential shredding bin. This practice was confirmed by dietary staff and acknowledged as improper by the DON, who was previously unaware of the issue.
The facility did not develop care plans for two residents receiving antibiotics and failed to implement an existing diabetes care plan for another resident, resulting in unmanaged medication use and repeated elevated blood glucose levels. These deficiencies were confirmed through record reviews and staff interviews.
A resident did not receive the necessary care to maintain or improve ROM, limited ROM, or mobility, and the facility did not ensure appropriate interventions were in place unless a decline was medically unavoidable.
Staff failed to maintain straight, unobstructed urinary catheter tubing for two residents with indwelling catheters, resulting in dependent loops and urine backflow. Despite facility policy requiring unobstructed urine flow and frequent checks, observations and staff interviews confirmed that catheter tubing was not properly positioned, leading to improper drainage.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
Surveyors identified that the medication error rate in the facility was 5 percent or greater, indicating a failure to maintain proper accuracy in medication administration.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Staff failed to use approved portion control utensils during meal service, resulting in some residents receiving less than the required amount of vegetables and others receiving more than the prescribed portion of sweet potato fries. The Dietary Supervisor confirmed that the correct procedures and equipment were not used, leading to inaccurate serving sizes.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature.
The facility did not prepare pureed foods, such as bread and beef, to the required consistency and shape for residents on a puree/level 4 diet. Instead, these foods were flat and did not hold their shape on the plate, as confirmed by the Dietary Supervisor and review of facility policies and recipes. This affected multiple residents who rely on pureed diets, making it more difficult for them to eat and potentially impacting their nutritional intake.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as observed by surveyors.
Surveyors found that a dumpster was overfilled, not fully covered, and surrounded by trash, including food spills and paper products. The DS and DON both confirmed that the dumpster should be kept closed and the area clean to prevent pests and contamination, in accordance with facility policy and the Food Code.
Staff failed to accurately and promptly document care for two residents, including urinary catheter care and the application of prescribed splints. In one case, an LVN provided catheter care but did not record it until hours later, and in another, a restorative nursing assistant documented splint application incorrectly. These actions resulted in medical records that did not accurately reflect the care provided, contrary to facility policy.
Staff failed to date oxygen tubing for a resident on oxygen therapy and did not label a urinary catheter system for another resident, contrary to facility protocols. Additionally, a CNA provided catheter care to a resident on enhanced barrier precautions without wearing the required isolation gown. These actions were confirmed by staff interviews and direct observation, with facility policies specifying the need for proper labeling and PPE use.
A resident with dementia, dysphagia, and a history of falls was found with their call light out of reach, despite care plan instructions and facility policy requiring accessibility. The CNA acknowledged forgetting to place the call light within reach, and the DON confirmed the importance of call light accessibility, especially for residents at risk of falls.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, resulting in a deficiency related to communication and notification procedures.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to follow the established care plan.
A resident with severe cognitive impairment and multiple medical conditions was prescribed Diclofenac Gel for pain, but the facility did not act on the consultant pharmacist's recommendation to clarify the specific application site with the physician. As a result, nurses lacked essential information for proper pain management, contrary to facility policy.
The facility did not ensure that each resident received an accurate assessment, as required. Inaccurate assessments were identified, which could affect care planning and service delivery for residents.
Multiple rooms in the facility were found to provide less than the required 80 square feet per resident, with 28 three-bed rooms offering only about 78.5 square feet per resident. Despite this, residents and staff did not report concerns, and observations showed adequate space for movement and care. The deficiency was identified through measurement and record review, and the facility had submitted a waiver request acknowledging the shortfall.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents did not receive pain management services in accordance with professional standards. One resident was given acetaminophen outside the prescribed pain scale range without physician consultation, while another was administered PRN hydrocodone-acetaminophen without documented attempts at nonpharmacological interventions, contrary to facility policy.
A resident with severe cognitive impairment and total dependence on staff for daily activities was found in bed with the call light inaccessible, as it was tucked between the mattress and pillow. An LVN confirmed the call light was not within reach, contrary to facility policy requiring accessibility for safety.
A resident with multiple medical conditions and moderate cognitive impairment had a care plan meeting that did not include the required IDT members such as a physician, RN, or CNA. Instead, only the POA, an LVN, an occupational therapist, social services, and dietary staff attended. Facility staff confirmed this practice did not follow the facility's own policy, which mandates participation from a physician, RN, and CNA in such meetings.
A resident with multiple myeloma and bone cancer did not receive their prescribed Lenalidomide as ordered due to a transcription error, resulting in the medication being administered only once instead of daily for 21 days. The error occurred when a nurse misunderstood the hospital discharge instructions and was not caught during the required verification process by the RN supervisor.
The facility did not ensure that the attending physician completed and documented an H&P within 72 hours of admission for two residents with moderate cognitive impairment and significant care needs. In both cases, the H&Ps were completed several days late, resulting in incomplete medical records.
A resident with multiple myeloma did not receive their prescribed Lenalidomide chemotherapy as ordered due to a transcription error by a nurse, resulting in only one dose being administered during a 21-day cycle. The error was not caught by medication administration checks or supervisory review, and was ultimately discovered by the resident's family member.
A resident with severe cognitive impairment and multiple diagnoses had their missing bilateral hearing aids reported, but the facility failed to promptly investigate the issue. The social service assistant did not receive proper endorsement from the previous director, leading to a delay in addressing the resident's right to retain personal property, contrary to the facility's policy.
The facility failed to ensure the designated Administrator (DADM) held a current and active NHA license and did not complete the background check prior to employment. The DADM began working without an active license, and the background check was completed after the hire date, contrary to facility policies.
The facility failed to maintain copies of advance directives in the medical records of three residents, leading to potential confusion regarding their healthcare wishes. Residents with severe cognitive impairments and various medical conditions, including cerebral vascular disease and epilepsy, had advance directive acknowledgment forms but lacked the actual documents in their records. The absence of these directives was confirmed by the ADON and DON, despite facility policy requiring them to be accessible in the medical record.
A LTC facility failed to follow professional standards by not measuring a resident's heart rate before administering Losartan and not rotating insulin injection sites for another resident. These actions were contrary to physician orders and facility policies, placing residents at risk for adverse health outcomes.
The facility did not label various food items with a use-by date, as observed during an inspection with the Dietary Director. This oversight was acknowledged by both the Dietary Director and the DON, who emphasized the importance of labeling to prevent spoilage. The facility's policy requires dry foods to be labeled and dated when stored in bins.
A resident with intact cognition and a history of surgical amputation was prescribed Trazadone and Vraylar without documented informed consent, violating their right to be informed and make decisions about their medical care. The facility's policy required informed consent for psychotropic medications, which was not obtained, as confirmed by a registered nurse during a review of the resident's medical chart.
A facility failed to create a comprehensive person-centered care plan for a resident's activity needs. The resident, with conditions including hypertension, diabetes, and legal blindness, was dependent on staff for daily care. Despite this, no care plan was developed to address their activity preferences, as confirmed by the Activity Director, which is against the facility's policy.
A resident admitted with hypertension and long-term anticoagulant use received a physician's order for Apixaban, but the care plan for anticoagulant use was delayed by 30 days. The ADON confirmed the care plan should have been initiated when the medication was ordered, as per facility policy, to address the serious safety risks associated with the medication.
A facility failed to reassess a resident's pain level after administering oxycodone for moderate to severe pain. The resident, with a history of lower back pain and a spinal fracture, received the medication but lacked a documented pain reassessment within the required 30 to 60 minutes. Interviews with staff confirmed the oversight, which was against the facility's pain management policy.
A resident with chronic conditions and intact cognition did not receive necessary dental services, including fillings and a crown, due to a lack of timely follow-up and documentation. Despite a physician order for dental consult and treatment, the facility failed to adhere to its policy on providing routine and emergency dental services.
The facility failed to prepare pureed egg noodles according to its recipe for 14 residents on a pureed diet. A staff member used chicken broth and an unmeasured amount of milk, contrary to the recipe, and added an incorrect amount of stabilizer. The Dietary Director found the noodles unpalatable, and the DON highlighted the importance of following recipes to ensure nutritional value and palatability.
A facility failed to transmit a resident's Discharge MDS within the required 14 days after completion, as per CMS guidelines. The resident, admitted with a leg fracture, was discharged shortly after admission. The MDS was completed on the discharge date but submitted nearly two months later. The MDSN and DON acknowledged the delay, which could interfere with the resident's admission to another facility.
The facility failed to meet the federal regulation requirement of 80 square feet per resident in 27 out of 49 rooms, each accommodating three residents with a total area of 235.7 square feet. Despite the deficiency, residents had sufficient space for mobility and the use of assistive devices. The facility submitted a Room Variance Waiver, indicating no obstructions in the rooms.
A resident's room was found in an unclean state with various items scattered on the floor, including plastic wrappers and a soiled washcloth. Despite the resident's intact cognition and need for assistance with daily activities, the facility failed to maintain a clean and homelike environment, as confirmed by a CNA and the DON. This deficiency had the potential to impact the resident's quality of life and increase the risk of infection and accidents.
Failure to Notify Physician of Elevated Blood Glucose per Order
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of an elevated blood sugar level as required by the physician’s order and facility policy. The resident was admitted with diagnoses including diabetes mellitus, hemiplegia, hemiparesis following cerebral infarction, and had moderately impaired cognition. The Minimum Data Set indicated the resident could make self-understood and understand others but was dependent on staff for multiple activities of daily living. A physician order dated 1/2/2026 directed staff to monitor blood sugar before meals and at bedtime and to notify the physician if blood sugar was less than 70 mg/dl or greater than 300 mg/dl. On 1/19/2026, the Weights and Vitals Summary and the Medication Administration Record documented that an LVN recorded the resident’s blood sugar as 335 mg/dl at approximately 9:00–9:30 p.m., which exceeded the threshold for required physician notification. During interviews and concurrent record reviews, the DON confirmed there was no documentation of any nursing intervention for monitoring hyperglycemia symptoms or of physician notification regarding the elevated blood sugar. The LVN acknowledged awareness of the order to notify the physician for blood sugars greater than 300 mg/dl and stated that they became busy and did not notify the physician when the 335 mg/dl result was obtained. The facility’s policy on “Change in a Resident’s Condition or Status” required prompt notification of the attending physician and documentation of changes in the resident’s condition, which was not followed in this instance.
Failure to Notify Physician of Unavailable Medications
Penalty
Summary
The facility failed to notify a resident's physician when several critical medications—methimazole, albuterol sulfate, and ipratropium bromide—were unavailable for administration upon the resident's admission. The resident had multiple significant diagnoses, including fractures, acute respiratory failure with hypoxia, and anxiety disorder, and was determined to lack capacity for decision-making. Medication orders for these drugs were in place, but the medications were not available at the scheduled administration times. Licensed nursing staff documented the unavailability of the medications in the resident's medical record and followed up with the pharmacy, which indicated the medications would be delivered the following day. However, the physician was not notified of the missed doses. The LVN involved stated that he reported the issue to RN supervisors and documented the situation but did not contact the physician because he did not receive instructions to do so from the supervisors. Further review and interviews confirmed there was no documented evidence that the physician was informed about the medication unavailability. Facility policy required prompt notification of the physician and resident representative regarding changes in the resident's condition or status, including when medications are not available. The Assistant Director of Nursing confirmed that the physician should have been notified to determine an alternative plan.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Interventions
Penalty
Summary
The facility failed to protect two residents from physical abuse when a physical altercation occurred between them. One resident, who had a history of not tolerating noise and demonstrated roommate incompatibility, became involved in a confrontation with their roommate over the use of a television. The altercation escalated when one resident turned off the other's TV, leading to a series of physical exchanges, including hitting with a closed fist and striking with a wheelchair footrest. Both residents sustained injuries, including scratches, cuts, and reported pain, requiring first aid and further medical evaluation. The facility did not follow its own policy and procedure regarding abuse prevention, which mandates protecting residents from abuse by anyone, including other residents. There was a lack of interventions in place to prevent the altercation, despite documented behavioral triggers and incompatibility between the two residents. Staff interviews confirmed that the altercation was avoidable and that the facility should have implemented measures to ensure a safe environment, particularly given the known behavioral history of one of the residents. Record reviews revealed that one resident had moderate cognitive impairment and required assistance with daily activities, while the other had severe cognitive impairment with psychotic disturbances. The care plan for the resident with behavioral triggers did not address these triggers or provide specific interventions to prevent outbursts. Staff acknowledged that a care plan should have been developed to address these issues, and the absence of such planning contributed to the occurrence of the physical abuse.
Failure to Develop Person-Centered Care Plan for Behavioral Triggers
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing the behavioral triggers of a resident with severe cognitive impairment and a history of behavioral disturbances. The resident, who was readmitted with diagnoses including unspecified dementia with psychotic disturbance and unspecified psychosis, was known to have anger triggered by environmental factors such as roommates' televisions being on or loud noises. Despite this, the care plan did not include specific interventions or measurable objectives to address these triggers, as confirmed by the Director of Nursing during record review and interview. An incident occurred in which the resident with behavioral triggers became involved in a physical altercation with his roommate. The altercation began after the resident turned off his roommate's television, leading to a series of escalating actions that resulted in both residents sustaining injuries. Staff interviews and documentation indicated that the resident's behavioral response was directly related to his known triggers, yet no individualized care plan interventions had been implemented to prevent such incidents. The facility's own policy required the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes to meet each resident's needs. However, the interdisciplinary team did not create a care plan specific to the resident's behavioral triggers, and no interventions were in place to address or mitigate these behaviors, contributing to the occurrence of the altercation.
Failure to Provide Privacy During Catheter Care
Penalty
Summary
Facility staff failed to provide privacy during indwelling urinary catheter care for two residents, resulting in a lack of dignity and potential psychosocial impact. In the first instance, a certified nurse assistant provided catheter care to a resident with Alzheimer's disease, aphasia, and neuromuscular bladder dysfunction without closing the curtain or door, leaving the resident exposed to the hallway. The resident was dependent on staff for all activities of daily living and was able to communicate her needs. The CNA acknowledged forgetting to provide privacy and recognized its importance for resident dignity. The Director of Nursing confirmed that privacy should have been ensured by closing the curtain or door before care. In the second instance, a licensed vocational nurse performed catheter care for another resident with hypertension, depression, and neuromuscular bladder dysfunction without closing the privacy curtain. The resident was capable of understanding and making decisions. The nurse admitted that privacy should have been provided and acknowledged the potential for exposure to others. The Director of Nursing reiterated that all residents have the right to privacy and that failure to provide it could cause embarrassment or impact psychological wellbeing. Facility policies reviewed confirmed the requirement to protect resident privacy and dignity during care.
Lack of Access to Survey Results and Advocate Communication
Penalty
Summary
Residents were not provided with easy access to view the facility's survey results and were not given the means to communicate with advocate agencies. This deficiency was identified based on observations that the required information was not made readily available to residents as mandated.
Failure to Maintain Advance Directives in Resident Medical Records
Penalty
Summary
The facility failed to ensure that copies of residents' Advance Directives (ADs) were maintained in their medical charts and were easily retrievable, as required by facility policy. For two residents, documentation in the Physician Order for Life-Sustaining Treatment (POLST) indicated the existence of an AD, but during concurrent interviews and record reviews, the Medical Records Assistant was unable to locate physical copies of these ADs in the residents' medical records. The Director of Nursing confirmed that a copy of the AD should be present in the physical chart for staff access. Both residents involved had significant medical histories, including conditions such as congestive heart failure, dementia, diabetes, Parkinson's disease, and epilepsy. Assessments indicated that these residents required varying levels of assistance with activities of daily living and were generally able to understand and communicate with others. The facility's policy, last reviewed in June 2025, specified that copies of executed advance directives must be obtained and maintained in a designated section of the medical record, but this was not followed in these cases.
Failure to Protect Resident PHI During Meal Ticket Disposal
Penalty
Summary
The facility failed to protect the confidentiality of residents' personal and medical information by not ensuring that documents containing protected health information (PHI) were properly shredded before disposal. During an observation of the dishwashing process, a dietary aide was seen discarding residents' meal tickets, which included names, room numbers, diet orders, and food allergies, directly into the trash. The dietary supervisor confirmed that this was the standard practice and acknowledged that the meal tickets contained sensitive resident information. The supervisor also stated that these documents should have been placed in a confidential bin for shredding, as disposing of them in regular trash exposed residents' information and violated privacy regulations. Further interviews with the Director of Nursing (DON) revealed that the DON was unaware that kitchen staff were discarding diet tickets in this manner. The DON confirmed that such documents contain PHI and should be disposed of securely, either by shredding or by blocking out identifying information. A review of the facility's policies indicated that all personnel are responsible for protecting PHI and that health information should not be disclosed except as permitted by law. The observed practice of discarding meal tickets in the trash was inconsistent with these policies and resulted in a failure to safeguard residents' confidential information.
Failure to Develop and Implement Comprehensive Care Plans for Medication Management
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in deficiencies related to medication management and monitoring. For two residents with orders for antibiotics—one for Bactrim for infection prophylaxis and another for amoxicillin following a tooth extraction—there were no care plans created to address the use of these medications. The Infection Preventionist Nurse confirmed that care plans should be developed for each antibiotic order to identify treatment goals and interventions to monitor for potential side effects or adverse effects, but this was not done for either resident. Additionally, a third resident with diabetes mellitus had a care plan in place to manage blood glucose levels, including specific interventions such as administering insulin per sliding scale, monitoring blood sugar, and notifying the physician if levels were outside set parameters. However, the care plan was not consistently implemented or followed, as evidenced by multiple instances of blood sugar readings above 300 mg/dL documented in the Medication Administration Record over two months. The Director of Nursing acknowledged that the care plan should have been followed to address the resident's elevated blood sugars. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables for each resident, to be developed and revised as resident conditions change. Despite this, the facility did not ensure that care plans were developed for antibiotic use or that the diabetes care plan was properly implemented and followed, as confirmed by record reviews and staff interviews.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Maintain Proper Urinary Catheter Positioning and Drainage
Penalty
Summary
Facility staff failed to ensure proper urinary catheter care for two residents with indwelling catheters, resulting in catheter tubing being observed with dependent loops and backflow of urine. For one resident with Alzheimer’s disease, aphasia, and neuromuscular bladder dysfunction, the catheter tubing was found hanging below the bed with a large dependent loop containing yellow liquid and sediment that back flowed toward the urine drainage port. Staff interviews confirmed that the tubing was not straight and that urine was not draining properly into the collection bag. A second resident, diagnosed with hypertension, hyperlipidemia, depression, neuromuscular bladder dysfunction, and a history of urinary tract infection, was also observed with a dependent loop in the catheter tubing. Staff, including an LVN and RN, acknowledged that the tubing was not straight, urine was present in the loop, and urine was not able to drain into the collection bag. Both staff members stated that dependent loops or kinks could prevent proper drainage and potentially cause urine to backflow into the resident. The facility’s policy and procedure for urinary catheter care, reviewed by surveyors, required staff to maintain unobstructed urine flow and to check frequently that residents were not lying on the catheter and that tubing was free of kinks. Despite this policy, observations and staff interviews confirmed that the required practices were not followed for both residents, resulting in improper catheter positioning and urine backflow.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper labeling and storage protocols for medications and biologicals within the facility. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Menu and Portion Control Procedures During Meal Service
Penalty
Summary
The facility failed to follow its established menu and portion control procedures, resulting in improper serving of vegetables and sweet potato fries to residents. During lunch service, a staff member used a perforated spoon, which was not an approved utensil, to portion carrots and broccoli. This method did not ensure the correct portion size was served, as confirmed by the Dietary Supervisor, who stated that the correct utensil should have been a perforated spoodle. The use of the incorrect utensil meant that residents may have received less than the required amount of vegetables. Additionally, another staff member overfilled a number 8 scoop with sweet potato fries by mashing them in, resulting in servings that exceeded the prescribed 1/2 cup portion size. The Dietary Supervisor acknowledged that this practice was incorrect and could lead to residents receiving more than the intended portion. The facility's policy and procedure on portion control required the use of specific portion control equipment to ensure accurate serving sizes, but these procedures were not followed during the observed meal service.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the food and beverages did not consistently meet standards for taste, appearance, or temperature at the time of service.
Failure to Prepare Pureed Foods to Required Consistency for Residents on Modified Diets
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs for residents on a puree/level 4 diet. During observation and interview, it was noted that puree bread and puree beef served to these residents were flat and did not hold their shape on the plate, contrary to the requirements outlined in the facility's diet manual and IDDSI guidelines. The Dietary Supervisor confirmed that the puree foods should be of a pudding-like consistency, smooth, and able to hold their shape, but acknowledged that the items in question were not prepared to these standards. The facility's recipes and policies specify that pureed foods must be smooth, free of lumps, and able to hold their shape, and must pass IDDSI level 4 testing requirements, which was not achieved in this instance. This deficiency affected 18 out of 101 residents on a puree/level 4 diet, as the improperly prepared foods could impact their ability to eat using silverware and potentially result in decreased food intake. The facility's documentation and staff interviews confirmed that the pureed foods did not meet the required consistency and presentation, as they were runny and did not maintain their shape, which could make them less appetizing and more difficult for residents to consume.
Failure to Follow Professional Standards for Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or the condition of individuals at the time of the deficiency are provided in the report.
Improper Disposal and Maintenance of Garbage Dumpster
Penalty
Summary
Surveyors observed that one of three dumpsters used for garbage disposal was overfilled, not completely covered, and had trash, including salsa drippings, plastic cans, paper towels, and empty cups, scattered on the floor around it. The Dietary Supervisor confirmed during the observation that the dumpster should always be kept closed to prevent flies, insects, and rodents from approaching the facility and to avoid trash spilling onto the ground. The supervisor acknowledged the presence of salsa spills and other refuse on the floor and stated that such conditions could allow insects, rodents, and flies to access the facility and potentially contaminate residents' food. The Director of Nursing also confirmed that the dumpster cover was not closed and that trash was present on the ground around the dumpster. The DON stated that the dumpster cover should be kept closed and the area kept clean to prevent flies, rodents, and unauthorized individuals from accessing the trash and potentially spreading infection to residents. A review of the facility's policies and the Food Code 2022 indicated that outside dumpsters must be kept closed and free of surrounding litter to minimize odors, prevent attraction and breeding of pests, and avoid contamination of food and food service areas.
Failure to Maintain Accurate and Timely Medical Records for Resident Care
Penalty
Summary
The facility failed to maintain timely and accurate medical records in accordance with accepted professional standards for two residents. For one resident with a history of hypertension, hyperlipidemia, depression, and neuromuscular bladder dysfunction, there was an active physician order for urinary catheter care every shift. On one occasion, the assigned LVN provided urinary catheter care in the morning but failed to document the care at the time it was provided. The care was later documented in the electronic treatment administration record several hours after the actual provision of care, resulting in an inaccurate record of when the care was performed. Both the LVN and the Director of Nursing acknowledged that this inaccuracy could lead to confusion for subsequent shifts and did not reflect the care as ordered by the physician. For another resident with diagnoses including hemiplegia, dysphagia, muscle weakness, contracture, and dementia, there were physician orders and care plans for the application of a left resting hand splint and left elbow extension splint, as well as passive range of motion (PROM) exercises. Observations and interviews confirmed that the restorative nursing assistant performed PROM and applied the splints as ordered. However, the documentation in the RNA Documentation Survey Report inaccurately indicated that splints were applied to both arms, when in fact only the left arm required splinting. The Assistant Director of Nursing confirmed that the documentation was inaccurate for the dates reviewed and emphasized the importance of accurate records to reflect the care provided. The facility's policy and procedure on charting and documentation required that all treatments and services performed be documented objectively, completely, and accurately, including the date and time of the procedure or treatment. In both cases, the failure to document care accurately and in a timely manner resulted in medical records that did not reflect the actual care provided, as required by facility policy and professional standards.
Failure to Date Medical Equipment and Adhere to PPE Protocols During Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several instances. For one resident receiving oxygen therapy, the nasal cannula oxygen tubing was not labeled with a date, contrary to facility protocol which requires tubing to be dated and replaced regularly. The Infection Preventionist Nurse confirmed that the tubing was undated and stated that dating is necessary for staff to know when to replace it, as part of infection prevention measures. In another case, a resident with an indwelling urinary catheter system did not have the catheter tubing and urine collection bag labeled with the date, time, and initials at the time of placement. The Licensed Vocational Nurse acknowledged the omission and explained that proper labeling is important to track when the catheter and bag were last changed, in accordance with physician orders and facility policy. The Director of Nursing also confirmed that the equipment should have been dated and initialed at the time of placement. Additionally, a Certified Nurse Assistant was observed providing urinary catheter care to a resident on enhanced barrier precautions without donning an isolation gown, as required by the facility's policy for residents with indwelling medical devices. The CNA admitted to forgetting to wear the gown and recognized the importance of following enhanced barrier precautions to reduce the risk of infection. Facility policy and signage were in place to remind staff of the required personal protective equipment for such care activities.
Call Light Not Accessible to Resident with Fall Risk
Penalty
Summary
A deficiency was identified when a resident with diagnoses including unspecified dementia, dysphagia, and a history of falls was found to have their call light out of reach. The resident's care plan specifically required that the call light be kept within reach and that the resident be encouraged to use it for assistance. During an observation, the resident was seated in a wheelchair near the foot of the bed, while the call light was wrapped and hung on the opposite side rail, making it inaccessible to the resident. When interviewed, the CNA responsible for the resident admitted to forgetting to place the call light within reach and acknowledged that it should not have been left on the opposite side of the bed. The DON confirmed that all call lights should be accessible to residents at all times and noted the resident's increased risk due to a history of falls. The facility's policy also required staff to ensure call lights are accessible to residents, but this was not followed in this instance.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping residents and their representatives informed about significant events impacting the resident's well-being.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.
Failure to Clarify Medication Order Location Following Pharmacist Review
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendation during the monthly Medication Regimen Review (MRR) for a resident who was prescribed Diclofenac Gel for pain management. The pharmacist's review specifically requested clarification from the physician regarding the exact location where the Diclofenac Gel should be applied. Despite this recommendation, the order remained unclarified, and the location of application was not specified in the resident's medical record. The resident involved had significant medical conditions, including diabetes mellitus and contact dermatitis, and was severely cognitively impaired, requiring total assistance with personal hygiene. The lack of clarification on the medication order meant that licensed nurses did not have the necessary information to know where to apply the medication, which was important for effective pain management. The facility's policy required timely communication and documentation of such recommendations, but these procedures were not followed in this instance.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which could impact the care planning process and the delivery of appropriate services to residents. Specific details about the residents involved or the nature of the inaccuracies in the assessments are not provided in the report.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide at least 80 square feet of space per resident in multiple resident bedrooms, as required by federal regulations. Specifically, 28 rooms housing three residents each were found to have only 235.7 square feet per room, resulting in approximately 78.5 square feet per resident, which is below the required minimum. This was confirmed through observation, interviews, and record review, including a waiver request letter from the Administrator acknowledging the deficiency. The rooms in question were equipped with beds, side tables, and resident care equipment, and allowed for freedom of movement and care provision, but did not meet the minimum space requirement. During the survey, no concerns were raised by residents or staff regarding the adequacy of room size, and general observations indicated that residents could move freely and that staff had sufficient space to provide care. The deficiency was identified based on the measured square footage and the number of residents per room, not on complaints or observed negative outcomes. The facility had previously submitted a written request for a continued waiver of the room size requirement.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Deficient Pain Management and Documentation for Two Residents
Penalty
Summary
Two deficiencies were identified regarding pain management for two residents. For the first resident, who had diagnoses including generalized arthritis, syncope, and chest pain, the facility failed to administer acetaminophen as prescribed. The physician's order specified acetaminophen for mild pain (pain scale 1-3), but the medication was administered when the resident reported a pain level of four. The Assistant Director of Nursing (ADON) confirmed that the medication should not have been given for a pain level outside the prescribed range and that the physician should have been contacted for an alternative order appropriate for the resident's pain level. For the second resident, who had diagnoses including Parkinson's disease, encephalopathy, and low back pain, the facility failed to ensure that licensed nurses attempted and documented nonpharmacological interventions before administering as-needed hydrocodone-acetaminophen for severe pain. The resident's care plan included non-medication interventions such as repositioning and distraction, but the Medication Administration Record (MAR) showed that these interventions were not documented as attempted prior to administering the narcotic medication on multiple occasions. The ADON acknowledged that nonpharmacological interventions should have been implemented and documented first, in accordance with facility policy. Both deficiencies were found to be inconsistent with the facility's policies on pain assessment and medication administration, which require medications to be given as prescribed and nonpharmacological interventions to be considered prior to administering narcotic pain medications.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
The facility failed to provide reasonable accommodation of a resident's needs and preferences by not ensuring that the call light was within reach for a resident who was dependent on staff for all activities of daily living and had severely impaired cognitive skills. During an observation, the resident was found in bed with the call light tucked between the mattress and pillow, making it inaccessible. This was confirmed during a concurrent interview and observation with a Licensed Vocational Nurse, who acknowledged that the call light was not within reach and stated it should always be accessible for safety. The resident involved had a history of intervertebral disc degeneration, muscle wasting and atrophy, limitations in activity due to disability, and adult failure to thrive. The Minimum Data Set assessment indicated the resident was dependent on staff for eating, hygiene, toileting, bathing, dressing, and mobility, and had severely impaired decision-making abilities. Facility policies reviewed indicated that staff are required to ensure call lights are accessible to residents in bed, on the toilet, in the shower, and on the floor, but this was not followed in this instance.
Failure to Ensure Required Interdisciplinary Team Attendance at Care Plan Meeting
Penalty
Summary
The facility failed to implement its policy and procedure regarding care planning by not ensuring that the required interdisciplinary team (IDT) members, including a physician, a registered nurse (RN), and a certified nurse assistant (CNA), were present during a scheduled care plan meeting for a resident. The care plan meeting, held within seven days of the resident's admission as required, was attended only by the resident's power of attorney (POA), an MDS nurse (who was a licensed vocational nurse), an occupational therapist, a social services staff member, and the dietary services supervisor. The absence of the physician, RN, and CNA was confirmed through interviews and review of the IDT Conference Notes. The resident involved had been admitted with multiple diagnoses, including generalized arthritis, syncope, type 2 diabetes mellitus, and depression. The Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and a need for varying levels of staff assistance with activities of daily living such as eating, oral hygiene, showering, personal hygiene, and mobility. Despite these complex needs, the care plan meeting did not include the clinical staff members responsible for the resident's direct care and medical management. Interviews with facility staff, including the Social Services Director, Assistant Director of Nursing, and Administrator, confirmed that the facility's practice was not in alignment with its own policy, which requires the attendance of a physician, RN, and CNA at IDT meetings. The Administrator acknowledged the importance of having these disciplines present to address medical questions, discuss clinical progress, and provide input on daily care routines. The facility's policy, last reviewed shortly before the incident, clearly outlined the required IDT composition, but this was not followed during the resident's care plan meeting.
Failure to Accurately Transcribe and Administer Chemotherapy Medication Order
Penalty
Summary
The facility failed to provide resident-centered care by not accurately transcribing a physician's order for Lenalidomide, a medication prescribed for a resident with multiple myeloma and bone cancer. The resident, who had moderate cognitive impairment and required significant assistance with daily activities, was admitted with discharge instructions from a general acute care hospital to receive Lenalidomide 20 mg by mouth once daily for the first 21 days of each 28-day cycle. However, the medication order was incorrectly transcribed as Lenalidomide 20 mg every 21 days instead of daily for 21 days on and seven days off. As a result of this transcription error, the resident received the medication only once during the specified period, with the medication administration record showing it was not given on the other days. The error was discovered after the resident's family questioned the remaining medication supply. The facility's policy required accurate recording of medication orders, including type, route, dosage, frequency, and strength, but this was not followed, and the error was not identified or corrected by the RN supervisor responsible for verifying admission orders.
Failure to Complete Timely Admission History and Physicals
Penalty
Summary
The facility failed to ensure that the attending physician completed and documented a History and Physical (H&P) within 72 hours of admission for two residents. For the first resident, who was admitted with diagnoses including primary generalized arthritis, syncope, and chest pain, the H&P was completed seven days after admission, exceeding the required timeframe. This resident had moderate cognitive impairment and required varying levels of assistance with daily activities. The Medical Records Director confirmed that the H&P was not completed within the required 72-hour window. For the second resident, admitted with Parkinson's disease, encephalopathy, and low back pain, the H&P was documented as a late entry and was signed nine days after admission. This resident also had moderate cognitive impairment and required assistance with daily care. The facility's policy requires that a completed and signed H&P be present in the medical record within 72 hours of admission, and the Director of Nursing or designee is responsible for auditing new admission charts to ensure compliance. The failure to complete timely H&Ps resulted in incomplete medical records for both residents.
Failure to Administer Chemotherapy Medication as Ordered Due to Transcription Error
Penalty
Summary
A deficiency occurred when a resident with multiple myeloma and bone cancer did not receive their prescribed medication, Lenalidomide, as ordered. The resident was admitted with instructions from the discharging hospital to receive Lenalidomide 20 mg orally once daily for the first 21 days of each 28-day cycle. However, the medication order was incorrectly transcribed by a desk nurse as 'one capsule by mouth one time a day every 21 days,' rather than daily for 21 days. As a result, the resident received only one dose of Lenalidomide during the period from 5/16/2025 to 5/31/2025, with the medication administered only on 5/22/2025 and not on the other days as required. The error was not identified by the facility's medication administration checks or by the RN supervisor responsible for verifying admission orders. The mistake was discovered when the resident's daughter questioned the number of capsules remaining in the medication bottle. The facility's policies required medications to be administered as prescribed and for orders to be accurately recorded, specifying type, route, dosage, frequency, and strength, but these procedures were not followed in this instance.
Failure to Investigate Missing Hearing Aids
Penalty
Summary
The facility failed to implement its grievance policy by not investigating a report regarding a resident's missing bilateral hearing aids. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, aphasia, and dysphagia following a cerebral infarction, had severely impaired cognition and was dependent on staff for various personal care activities. Despite the report of the missing hearing aids being documented, the investigation was not completed promptly, leading to a delay in addressing the resident's right to retain and use personal property. Interviews with facility staff revealed that the social service assistant was aware of the missing hearing aids but did not receive an endorsement from the previous social service director, resulting in a lack of immediate follow-up. The facility's policy required prompt response and investigation of theft or misappropriation complaints, but this was not adhered to, as evidenced by the delayed completion of the investigation. The failure to act promptly on the missing hearing aids was acknowledged by the social service assistant and director, who recognized the negative impact on the resident's well-being.
Failure to Ensure Administrator Licensing and Background Check
Penalty
Summary
The facility failed to ensure that the designated Administrator (DADM) held a current and active license from the State to serve as a nursing home administrator (NHA). The DADM began working at the facility on 9/9/2024, and signed the job description for an Administrator, which required maintaining licensing credentials. However, a review of the California Department Public Health (CDPH) Licensing and Certification (L&C) Verification Search Page revealed no active and current NHA license for the DADM. Interviews with the Director of Nursing (DON) and the DADM confirmed that the DADM's license was pending and that the Executive Director (ED) was aware of the inactive status at the time of hire. Despite this, the DADM was performing the duties of an Administrator. Additionally, the facility did not implement its policy and procedures for ensuring the background check of the DADM was initiated and completed prior to employment. The DADM's background check was requested on 9/18/2024 and completed on 9/19/2024, after the official hire date of 9/9/2024. The Director of Staff Development (DSD) confirmed that the background check should have been completed before employment, as per the facility's policy and procedures. The facility's policies and procedures, last revised in 8/2024, stated that a licensed administrator is responsible for the day-to-day functions of the facility, and in their absence, the assistant administrator or director of nursing services is authorized to act on their behalf. The hiring policy, last reviewed on 6/26/2024, required that certifications and licenses be considered in determining an applicant's qualifications. The failure to adhere to these policies resulted in the DADM operating the facility without an active NHA license and without a completed background check prior to employment.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that copies of advance directives were kept in the medical records of three residents, leading to potential confusion and conflict with the residents' healthcare wishes. Resident 83, admitted with cerebral vascular disease, chronic kidney disease, and type 2 diabetes, had severely impaired cognition and was dependent on staff for daily activities. Despite having an advance directive acknowledgment form, the actual document was missing from the resident's clinical record, as confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). Similarly, Resident 49, admitted with a displaced fracture, epilepsy, and dysphagia, also had severely impaired cognition and was dependent on staff for assistance. The resident's care plan indicated the presence of an advance directive, but the document was not found in the clinical record. Both the ADON and DON acknowledged the absence of the advance directive in the resident's chart, which should have been available to guide staff in respecting the resident's wishes. Resident 18, who was legally blind and had hypertension and type 2 diabetes, also had an advance directive acknowledgment form but lacked the actual document in both electronic and physical records. The ADON confirmed the absence of the advance directive, emphasizing the importance of having it readily accessible to ensure the resident's healthcare wishes are followed. The facility's policy requires advance directives to be placed in a prominent, accessible location in the medical record, but this was not adhered to for these residents.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to professional standards of practice by not ensuring that a resident's heart rate was measured before administering Losartan, a medication used to treat high blood pressure. This deficiency was observed when a Licensed Vocational Nurse (LVN) prepared and administered Losartan to a resident without checking their heart rate, despite a physician's order to do so. The resident had a history of hypertension and was at risk for bradycardia, which could lead to dizziness and falls. The Assistant Director of Nursing confirmed that the nurse should have followed the physician's order to check the heart rate before administering the medication. Additionally, the facility did not consistently rotate insulin injection sites for another resident, as required by professional standards. The resident, who had type 2 diabetes mellitus, received insulin injections in the same areas repeatedly over a period of time. This practice was contrary to the resident's care plan, which specified that injection sites should be rotated to prevent complications such as lipodystrophy. Medical Records staff and a Registered Nurse reviewed the resident's diabetic administration record and confirmed that the injection sites were not being rotated as required. The facility's policies and procedures for administering medications and insulin were not followed, leading to these deficiencies. The policy for administering medications required checking vital signs when necessary, and the insulin administration policy required rotating injection sites. These lapses in following established protocols placed the residents at risk for adverse health outcomes.
Failure to Label Food with Use-By Dates
Penalty
Summary
The facility failed to adhere to professional standards for food storage by not labeling food items with a use-by date. During an observation and interview with the Dietary Director, it was noted that various food items, including instant pudding mixes, cornbread mixes, brownie mixes, cheesecake mixes, premium topping, seedless raisins, and soup boxes, were stored without a use-by date label. The Dietary Director acknowledged that the absence of such labels could potentially affect residents' health. Additionally, the Director of Nursing confirmed that food should always be labeled with a use-by date to prevent spoilage. A review of the facility's policy on food receiving and storage, dated November 2022, indicated that dry foods stored in bins should be removed from their original packaging, labeled, and dated.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for a resident, violating their right to be informed and make decisions about their medical care. The resident, who was admitted with orthopedic aftercare following surgical amputation and had intact cognition, was prescribed Trazadone and Vraylar without documented consent. The resident's medical records indicated that they had the capacity to understand and make decisions, yet the facility did not secure the necessary consents for these medications. During a review of the resident's medical chart, it was confirmed by a registered nurse that there was no medication consent for the use of Trazadone and Vraylar. The facility's policy required informed consent to be obtained and documented before administering psychotropic medications, which was not adhered to in this case. The facility's policy also emphasized the resident's right to be informed of their medical condition and participate in care planning and treatment, which was not upheld in this instance.
Failure to Develop Person-Centered Care Plan for Resident Activities
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 18, specifically regarding their activity needs. Resident 18 was admitted with diagnoses including hypertension, type 2 diabetes mellitus, and legal blindness. The Minimum Data Set (MDS) assessment indicated that Resident 18 had impaired cognitive skills for daily decision-making and was totally dependent on staff for personal care activities such as toileting, showering, dressing, and personal hygiene. During a review of Resident 18's care plans, it was found that no care plan had been developed to address the resident's activity preferences, which is a requirement according to the facility's policy. The Activity Director confirmed that a person-centered care plan should have been created to set goals and interventions tailored to the resident's needs, such as including strolls in the facility patio. The absence of such a care plan meant there were no established objectives or timetables to meet Resident 18's psychosocial and functional needs.
Delayed Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident within the required timeframe. The resident, who was admitted with diagnoses including hypertension and long-term use of anticoagulants, received a physician's order for Apixaban, an anticoagulant medication, on June 23, 2024. However, the care plan addressing the use of anticoagulants was not developed until July 22, 2024, which was 30 days after the medication was ordered. This delay in care planning was identified during a review of the resident's records and confirmed by the Assistant Director of Nursing (ADON). The ADON acknowledged that the care plan should have been initiated when the Apixaban was first ordered, as the medication carries a black box warning requiring specific interventions to mitigate serious adverse effects. The facility's policy on comprehensive person-centered care plans, last reviewed on June 26, 2024, mandates that such plans include measurable objectives and timetables to meet the resident's needs. The failure to timely develop the care plan had the potential to impact the resident's care, particularly in managing the risks associated with anticoagulant therapy.
Failure to Reassess Pain After Oxycodone Administration
Penalty
Summary
The facility failed to reassess the pain level of Resident 156 after administering oxycodone, a medication used to treat pain. Resident 156, who was admitted with diagnoses including lower back pain and a wedge compression fracture of the third lumbar vertebra, was prescribed oxycodone 5 mg to be taken every six hours as needed for moderate to severe pain. On a specific date, the resident received oxycodone at 9:47 a.m., but there was no documented evidence that the resident's pain level was reassessed 30 minutes to one hour after administration, as required by the facility's policy. Interviews and record reviews with the Minimum Data Set Nurse (MDSN) and Licensed Vocational Nurse 4 (LVN 4) confirmed the lack of pain reassessment documentation. The facility's policy on pain assessment and management, last reviewed in June 2024, mandates that acute pain should be reassessed every 30 to 60 minutes until relief is obtained. The absence of a documented pain reassessment increased the risk of Resident 156 experiencing untreated and prolonged pain.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services, which placed the resident at increased risk for deterioration of oral hygiene and gum disease. The resident, who was admitted to the facility with diagnoses including chronic obstructive pulmonary disease and essential hypertension, had intact cognition and required supervision for personal care activities, including oral hygiene. A physician order for a dentistry consult with follow-up treatment as needed was noted upon the resident's admission. However, despite a dental note indicating the need for fillings and a crown, there was no documentation of approval for these treatments after a certain date. Interviews with facility staff revealed a lack of timely follow-up on the resident's dental care needs. The Social Service Director confirmed the absence of documentation regarding the approval for the resident's dental treatments, and the Director of Nursing acknowledged the importance of timely dental visits to prevent oral health deterioration. The facility's policy on dental services, revised in June 2024, stated that routine and emergency dental services should be available to meet residents' oral health needs according to their assessment and care plan, which was not adhered to in this case.
Improper Preparation of Pureed Egg Noodles
Penalty
Summary
The facility failed to prepare pureed egg noodles according to its established recipe for 14 residents on a pureed diet. During an observation, a staff member, identified as C1, was seen preparing the noodles using chicken broth and an unmeasured amount of milk, contrary to the facility's recipe which specified the use of milk only and no chicken broth. Additionally, C1 used an incorrect amount of stabilizer, adding eight ounces instead of the recommended seven to twelve tablespoons. This deviation from the recipe was confirmed by the Dietary Director (DD) during a review of the facility's puree pasta recipe. The Dietary Director later sampled the prepared egg noodles and found them unpalatable, noting an excessive use of stabilizer. The Director of Nursing (DON) emphasized the importance of following recipes to ensure the nutritional value and palatability of food, as deviations could affect residents' nutrition and potentially lead to weight loss. The facility's policy, dated June 2024, mandates that each resident is provided with a nourishing, palatable, and well-balanced diet that meets their nutritional and special dietary needs.
Failure to Timely Transmit Discharge MDS
Penalty
Summary
The facility failed to transmit a resident's Discharge Minimum Data Set (MDS) within the required 14 days after the completion date, as mandated by the Centers for Medicare and Medicaid Services (CMS). This deficiency was identified for one resident, who was admitted to the facility with a right lower leg fracture and was discharged shortly after admission. The MDS, which is a standardized assessment and care screening tool, was completed on the resident's discharge date but was not submitted to CMS until nearly two months later. During interviews, the MDS Registered Nurse (MDSN) acknowledged that the MDS was submitted late and could not provide a reason for the delay. The Director of Nursing (DON) confirmed that the MDS should have been submitted within the 14-day timeframe to ensure CMS had an accurate assessment of the resident's condition. The facility's policy, which aligns with CMS's Resident Assessment Instrument (RAI) Manual, also requires timely submission of MDS assessments. The delay in submission had the potential to interfere with the resident's admission to another facility.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 27 out of 49 resident rooms met the federal regulation requirement of 80 square feet per resident in multiple resident rooms. During the recertification survey, it was observed that these rooms, which had an application for variance, did not meet the required square footage. Each of these rooms was designed to accommodate three residents, with a total area of 235.7 square feet, falling short of the minimum requirement of 240 square feet for a three-bedroom setup. This deficiency was identified through observation, interviews, and record reviews conducted during the survey. Despite the deficiency in room size, it was noted that the residents in these rooms had sufficient space for mobility and the use of assistive devices such as wheelchairs, walkers, or canes. The room variance did not appear to affect the care and services provided by the nursing staff. The facility had submitted an application for a Room Variance Waiver, indicating that the rooms did not have any obstructions that would interfere with free movement or the provision of care, health, safety, and dignity for the residents.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for one of the residents, identified as Resident 1. On August 28, 2024, the floor of Resident 1's room was observed to be soiled with multiple plastic wrappers, two plastic containers, one plastic spoon, several pieces of paper, and a soiled washcloth around the bed. Resident 1, who has been residing in the facility for several years, was unsure how long the items had been on the floor. The resident's medical history includes chronic obstructive pulmonary disease, paraplegia, schizophrenia, major depressive disorder, and anxiety. Despite having intact cognition and the capacity to understand and make decisions, Resident 1 required assistance with various daily activities, including setup or clean-up assistance with eating and moderate assistance with personal hygiene. The observations were confirmed by a Certified Nursing Attendant (CNA 1) and the Director of Nursing (DON), who acknowledged that the room did not meet the standards of a clean and homelike environment as per the facility's policy. The facility's policy emphasizes providing a safe, clean, and comfortable environment that reflects a personalized, homelike setting. The failure to maintain cleanliness in Resident 1's room had the potential to negatively impact the resident's quality of life and increase the risk of infection and accidents, as confirmed 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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