Western Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2190 W Adams Blvd, Los Angeles, California 90018
- CMS Provider Number
- 555069
- Inspections on file
- 39
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Western Convalescent Hospital during CMS and state inspections, most recent first.
A resident with a GT, tracheostomy, respiratory failure, dysphagia, and severely impaired cognition, who was assessed as NPO and receiving total nutrition via GT, was mistakenly given another resident’s breakfast tray and consumed multiple food items and thickened liquids despite no diet order for oral intake. A CNA provided the tray in error, and an LVN and an RN, both aware the resident was NPO and without an order for oral feeding, failed to promptly notify the physician or document the incident in the medical record, contrary to facility policies requiring written diet orders before serving meals and complete, accurate documentation of incidents and changes in condition.
Three dependent residents with significant cognitive and physical impairments were observed with poor oral hygiene, including thick secretions and dry, cracked lips. Staff interviews and record reviews confirmed that required oral care interventions, such as use of oral care kits and regular moisturizing, were not consistently provided as outlined in care plans and facility policy.
The facility failed to implement OT recommendations for hand splints and obtain physician orders for two residents with hand contractures, and did not reassess another resident's mobility needs after readmission and changes in condition. These actions were not in accordance with facility policy and led to residents not receiving appropriate interventions to maintain or improve range of motion.
A resident with significant cognitive and physical impairments sustained an unexplained right thumb fracture that was identified by nursing staff and confirmed by x-ray. Despite facility policy and federal regulations requiring immediate reporting of such injuries as potential abuse, the incident was not reported to CDPH within the mandated timeframe, and the results of the internal investigation were not sent to the state agency.
A resident with multiple medical conditions did not receive a complete dose of IV antibiotic as ordered, as the medication was not fully infused and the IV site was found dislodged and not properly maintained. Nursing staff did not ensure the IV was administered completely or monitor the site according to facility policy.
A resident with COPD and respiratory failure was observed receiving oxygen at a higher flow rate than ordered by the physician, despite care plan instructions and facility policy requiring administration as prescribed and regular monitoring. Staff confirmed the discrepancy between the order and the oxygen delivered.
A resident with complex medical needs did not have complete and accurate documentation in their clinical record regarding the application and tolerance of prescribed splint services. Although physician orders required daily use of hand and knee splints, staff failed to document the resident's inability to tolerate these devices on certain days, and the records inaccurately indicated that the services were provided. Facility policy required objective and accurate documentation, which was not met in this case.
A resident with severe cognitive impairment and multiple medical conditions was admitted without a fully completed POLST form. Key sections of the POLST, including those for CPR, medical interventions, nutrition, and required signatures, were left blank, and the form was not signed by the resident's legal decision maker. Staff interviews confirmed the form's incompleteness and acknowledged that it should have been fully filled out according to facility policy.
A resident with severe cognitive impairment and complex medical needs was transferred to a hospital, but staff failed to document the transfer, including the resident's clinical condition and vital signs. The Clinical Manager confirmed the medical record was incomplete, and facility policy requiring thorough documentation was not followed.
A resident with multiple stage 4 and unstageable pressure ulcers, severe cognitive impairment, and total dependence on staff did not have a comprehensive care plan developed after admission. Although a baseline care plan was in place, facility staff confirmed that the required interdisciplinary comprehensive care plan addressing wound care was not completed, contrary to facility policy.
A resident with multiple Stage 4 and unstageable pressure ulcers, who was totally dependent on staff and had impaired cognition, did not receive weekly reassessment and documentation of their wounds as required. The treatment nurse failed to complete scheduled evaluations, and facility policies did not mandate weekly reassessment, resulting in inadequate monitoring of the resident's pressure ulcers.
A resident with multiple complex diagnoses and total dependence on staff for ADLs did not have a comprehensive, person-centered care plan. The care plan lacked specific interventions, such as the need for two-person assistance, and did not include measurable objectives or timetables, contrary to facility policy. The DON confirmed the care plan was not individualized to ensure the resident's needs were met.
A resident with severe mobility and cognitive impairments, dependent on staff for all ADLs, was not provided the required two-person assist during care activities. Despite the care plan and facility policy specifying the need for two-person assistance to prevent accidents and injuries, a CNA performed care alone, and the DON confirmed this was not in accordance with the resident's care plan.
The facility failed to implement its infection control program, as a Laundry Aide did not perform hand hygiene or change gloves and gown after handling dirty linens, risking cross-contamination. Additionally, a resident's opened strawberry jam was not refrigerated as required, posing a risk of foodborne illness. The facility lacked a refrigerator for personal food items, contrary to its policy discouraging outside food due to safety concerns.
The facility failed to obtain and document informed consent for psychotropic medications for two residents. One resident received lorazepam and sertraline without proper consent, and another was prescribed duloxetine without documented consent. The Director of Nursing and Assistant Director of Nursing confirmed these oversights, which violated the facility's policy requiring informed consent before treatment.
The facility failed to ensure that room windows were able to close properly, resulting in cold conditions for three residents. Observations revealed that the windows were open and unable to be closed, with one window cracked and others taped. Residents reported the issue, and the Maintenance Aide acknowledged it but required an outside company for replacement. The Administrator confirmed a request for replacement was made, but the facility's policy on maintaining comfortable temperatures was not met.
A facility failed to monitor a resident's weight weekly as ordered, missing several scheduled weigh-ins, which could have impacted the resident's health. Additionally, another resident's orthostatic blood pressure was inaccurately measured, with identical readings recorded for lying and sitting positions, suggesting procedural errors. These deficiencies indicate non-compliance with the facility's policies on weight and blood pressure monitoring.
A facility failed to set a low air loss mattress correctly for a resident with a Stage 4 pressure ulcer, risking ineffective wound healing. Additionally, another resident at risk for pressure injuries was found without physician-ordered Prevalon boots, increasing the risk of skin breakdown. These deficiencies indicate non-compliance with care plans and physician orders.
The facility failed to provide appropriate ROM care for several residents, including not adhering to physician orders for splint application and duration, and missing RNA treatments. Residents did not receive timely annual JMAs, and splints were applied without orders, risking further decline in joint mobility. Staff interviews highlighted the importance of following orders to prevent worsening contractures.
The facility failed to provide adequate RNA staffing, affecting 81 residents with physician's orders for RNA treatments. Staffing records showed inconsistencies, with RNAs often reassigned to CNA duties due to CNA shortages. This led to difficulties in fulfilling RNA responsibilities, risking residents' range of motion and mobility. The Director of Nursing highlighted the importance of sufficient RNA staffing to prevent contractures and maintain joint mobility.
Two LVNs at the facility demonstrated inadequate competency in assessing orthostatic hypotension, as they misunderstood the procedure for taking blood pressure readings in different positions. This deficiency could lead to delays in care and potential resident injury. The DSD clarified the correct procedure, emphasizing the need for proper training to ensure quality care.
A facility failed to monitor a resident's blood pressure when administering amlodipine, as required by the care plan and physician's order. The resident's care plan indicated a risk for elevated blood pressure and falls due to antihypertensive medications, necessitating monitoring of vital signs. However, the MAR lacked documented blood pressure readings during the administration period, which was confirmed by the DON. This failure to document vital signs as per facility policy increased the risk of adverse effects.
A facility failed to ensure a resident was not prescribed Seroquel without an appropriate diagnosis, as the resident's records did not support a mental illness diagnosis. Additionally, the facility did not define or monitor behaviors related to lorazepam use for another resident, failing to document the resident's response to the medication. The Director of Nursing acknowledged these deficiencies, which contravened the facility's policy on psychotropic medication management.
A facility exceeded the acceptable medication error rate with two errors affecting two residents. One resident received an incorrect strength of cranberry supplement, while another was given a tablet instead of a liquid multivitamin. The errors were due to a failure to follow physician orders and proper medication labeling, as admitted by the LVN involved.
A resident did not receive the correct laboratory tests as ordered by the physician to monitor thyroid function due to Seroquel use. The care plan indicated a risk for dehydration, and a thyroid panel was recommended by the pharmacist. However, only a thyroid peroxidase and thyroglobulin antibody test was performed, not the complete thyroid panel. RN 2 confirmed the discrepancy, noting the tests conducted were not equivalent to the ordered thyroid panel.
The facility failed to follow the standardized recipes for residents on a soft and bite-size diet, serving whole bread instead of appropriately sized pieces. The menu did not reflect the new IDDSI standards, leading to inconsistencies with physician diet orders. This discrepancy was confirmed by dietary staff and posed potential risks to residents.
The facility failed to ensure sanitary food preparation practices, as a can opener blade in the kitchen was found dirty and worn, potentially harboring harmful bacteria. The Dietary Supervisor confirmed the residue and was unsure of the last cleaning. This deficiency risked cross-contamination for 47 out of 109 residents receiving food from the facility.
The facility lacks a comprehensive policy for storing and reheating food brought by family and visitors, as confirmed by interviews with staff including the Dietary Supervisor, charge nurse, and DON. The current policy discourages outside food due to safety concerns but does not provide procedures for safe storage, leading to potential foodborne illness risks.
A resident was found with all four bed rails raised without a proper order or informed consent, contrary to facility policy. The resident did not request the bed rails and had no recent history of falls. The facility's policy requires an assessment, consent, and order for bed rail use, which were not present in this case, potentially restricting the resident's movement and posing a risk of injury.
A facility failed to document a resident's diabetes mellitus (DM) diagnosis on the Minimum Data Set (MDS), despite a physician's order for Metformin. The MDS Coordinator acknowledged the omission, which is crucial for accurate care planning.
A resident's room was found to have an unsafe setup of extension cords, posing a fire and fall risk. Personal chargers were plugged into an extension cord lying on the ground and connected to another cord under the bed. Staff acknowledged the hazard, and the facility's policy prohibits such use of extension cords.
A resident experienced falls and injuries due to the facility's failure to adhere to medication hold parameters for amlodipine, which was administered 81 times despite the resident's systolic blood pressure being below the prescribed threshold. The resident's care plan noted a risk of falls related to antihypertensive medication, but no specific interventions were implemented. The DON acknowledged the oversight, linking the medication errors to the resident's falls.
The facility failed to implement infection control measures for two residents. A resident's foley catheter bag was found on the floor, and LVNs did not wear PPE or perform hand hygiene during wound care, despite Enhanced Barrier Precautions. Another resident received wound care without proper hand hygiene between glove changes. These actions were against the facility's infection control policies.
The facility failed to maintain a safe, clean, and homelike environment for two residents, leading to unsanitary conditions. Observations revealed dry brown spots on ceilings, peeling paint, and dirt in rooms of residents with significant medical needs. Staff interviews confirmed awareness of these issues, but maintenance and cleaning were not adequately performed, contrary to facility policies.
A resident with cognitive and functional deficits was found with stained bed sheets that were not changed by the CNA after providing a bed bath. The facility's policy requires daily linen changes, especially when soiled, to maintain a clean environment and prevent infection. Staff interviews confirmed the importance of this practice to uphold the resident's right to a clean living space.
A resident with severe cognitive impairment and multiple health conditions was found to have a skin discoloration on the wrist, indicative of potential abuse. The facility failed to report this allegation to the CDPH within the required two-hour timeframe, resulting in a delayed investigation and placing the resident at risk for further abuse.
A resident with severe cognitive impairment and multiple diagnoses did not receive timely toileting hygiene due to combative behavior. A CNA stopped providing care, resulting in a 30-minute delay until the resident's family member assisted. The DON noted the lack of documentation and emphasized the importance of timely care to prevent skin breakdown.
The facility failed to implement proper infection control practices, as oxygen nasal cannulas for two residents were improperly stored, hanging uncovered on GT feeding poles, contrary to policy. Additionally, two other residents had unclean gastrostomy tube sites, with one showing dried serous sanguineous spots and redness, and another with dried brownish spots on the dressing. Staff interviews confirmed these practices were against facility policies, posing a risk of infection.
A resident with a history of cerebral infarction exhibited slurred speech and other stroke symptoms, but the LVN did not notify the physician, leading to delayed medical care. The resident was later diagnosed with an acute subdural hematoma at a hospital. The facility's policy requires prompt physician notification for changes in condition, which was not followed.
A resident with a history of stroke experienced a change of condition, including altered consciousness and right arm weakness. An LVN failed to notify the physician or RN, delaying care. The DON stated these symptoms should have been reported immediately, as per facility policy.
A resident with hypotension was prescribed Midodrine with instructions to hold the medication if systolic blood pressure exceeded 110 mmHg. However, the medication was administered on three occasions despite the resident's blood pressure being above the threshold. Interviews with the LVN and DON confirmed the oversight, which was contrary to the facility's medication administration policy.
NPO Resident Incorrectly Served Meal and Incident Not Timely Reported or Documented
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards for a resident with a gastrostomy tube, tracheostomy, respiratory failure, dysphagia, and severely impaired cognitive status. The resident’s MDS indicated they were rarely able to be understood, sometimes able to understand others, and had severely impaired decision-making, with eating not attempted due to medical or safety concerns. The resident’s orders from 3/24/2026 through 4/21/2026 included aspiration precautions and Glucerna via GT, with no order for oral intake, and the nutritional assessment documented the resident as NPO with total nutrition via GT. The baseline care plan directed staff to provide diet and fluids as ordered and GT feeding and care as ordered. Despite these orders and assessments, a CNA mistakenly provided the resident with a breakfast tray intended for another resident, and the resident consumed bacon, toast, dry cereal, scrambled eggs, and thickened liquids. An LVN observed the resident eating and knew the resident was NPO and had no order for oral intake but did not notify the physician or document the incident in the medical record. An RN was also notified that the resident was eating while NPO and acknowledged that she should have notified the physician and documented the event but did not do so. The DON later confirmed that the incident was not documented in the medical record until eight days after it occurred and that the physician was not notified until seven days after the incident. Facility policies required that a written diet order appear in the medical record before a resident may be served and that changes in condition, events, incidents, or accidents be objectively, completely, and accurately documented to facilitate communication among the interdisciplinary team.
Failure to Provide Adequate Oral Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate oral hygiene to three out of five sampled residents who were dependent on staff for activities of daily living. Observations revealed that these residents had visible signs of poor oral care, such as thick, white secretions, white crusty discharges, and dry, cracked lips. Interviews with staff and residents confirmed that oral care was not consistently provided as required by the residents' care plans and facility policies. Resident 2, who had diagnoses including hemiplegia, hemiparesis, diabetes, and hypertension, was observed with thick, white secretions in the mouth and reported that nurses did not provide daily oral care. Resident 3, with severe cognitive impairment and similar physical limitations, was found with white crusty discharges on the lips, and staff acknowledged that oral care was difficult but still necessary. Resident 4, also dependent on staff and with severe cognitive impairment, was observed with dry, crusty mucus on the lips, and staff noted that moisturizer was not always applied as part of oral care. Record reviews for all three residents showed that their care plans required daily and every shift oral care, including the use of oral care kits with Chlorhexidine Gluconate, brushing teeth twice daily, and moisturizing the lips. Despite these documented interventions, the observed conditions and staff interviews indicated that these measures were not consistently implemented, resulting in poor oral hygiene for the affected residents.
Failure to Implement Therapy Recommendations and Reassess Mobility Needs
Penalty
Summary
The facility failed to implement occupational therapy (OT) recommendations for hand splints and to obtain physician orders for two residents with significant or developing hand contractures. One resident, who was non-ambulatory and dependent on staff for all activities of daily living, had severe loss of passive range of motion in both hands. Despite an OT evaluation recommending hand rolls for both hands to reduce pain and maintain joint mobility, the resident was not assessed for hand splints, and no physician order was obtained until after the surveyor's visit. Observations confirmed the resident's hands were contracted in a fist position, and the OT acknowledged that the absence of hand splints could worsen the contractures. Another resident with muscle weakness and a history of respiratory failure was also identified as being at risk for contracture development. The OT evaluation recommended resting hand splints for both hands, but the OT did not follow up to obtain a physician order, and the resident had not worn splints for over a month. The resident was observed with contracted fingers and reported not receiving restorative nursing assistance for finger exercises. The facility's policy required the therapist to order splints and ensure physician orders were in place, but this was not followed. Additionally, the facility did not implement its policy for screening and reassessment after a change in condition or readmission for another resident with a history of traumatic brain injury and severe contractures. After readmission, the resident was ordered to receive hand and knee splints, but the rehabilitation department did not formally assess the resident prior to resuming these services. When the resident was unable to tolerate the splints, no new recommendations were made, and the required reassessment was not completed. The facility's policy specified that a PT or OT should complete a joint mobility screening after readmission or a change in condition, but this was not done.
Failure to Timely Report Unexplained Fracture as Possible Abuse
Penalty
Summary
The facility failed to report a resident's right thumb fracture to the California Department of Public Health (CDPH) within the required two-hour timeframe, as mandated by federal regulations. The resident, who had a history of tracheostomy, gastrostomy, ventilator dependence, and dementia, was found to have redness and swelling on the right thumb, which was later confirmed by x-ray to be an acute nondisplaced fracture. The resident was highly dependent, unable to communicate, and lacked decision-making capacity. The injury was not witnessed by staff, and there was no explanation provided by the resident due to their condition. Despite the facility's policy requiring immediate reporting of suspected abuse or unexplained injuries, the Administrator, who also served as the abuse coordinator, did not report the incident to CDPH, citing the absence of hospitalization or surgical intervention. The Registered Nurse involved recognized that the injury could be a result of abuse or mishandling, as it was unexplained and severe. The facility also failed to send the results of the abuse investigation to the State Survey Agency, contrary to their own policies and regulatory requirements.
Failure to Ensure Complete IV Antibiotic Administration and Secure IV Site
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infection, dysphagia following cerebral infarction, and type 2 diabetes mellitus did not receive intravenous (IV) antibiotic medication as ordered. The physician's order and care plan required the administration of Ertapenem Sodium 1 gram IV every 24 hours for a UTI, with the expectation that the IV site would be maintained and free of complications. However, during observation, it was found that the IV antibiotic bag, which should have been completely infused by 6:30 a.m., still had 40 cc remaining at 11:15 a.m., indicating the medication was not fully administered. The Assistant Director of Nursing confirmed that the medication should have been completely infused and that failure to do so would not treat the infection. Further observation revealed that the resident's saline lock needle tip was dislodged and lying on the skin, rather than being properly inserted into the vein. The registered nurse acknowledged that a patent saline lock should be in the vein to administer IV medications. Review of facility policy confirmed that nurses are required to monitor the IV site frequently for complications and ensure proper administration. These failures resulted in the resident not receiving the complete dose of antibiotic medication and the IV site not being securely maintained.
Failure to Administer Oxygen as Ordered
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), respiratory failure, urinary tract infection, dysphagia following cerebral infarction, and type 2 diabetes mellitus was admitted and readmitted to the facility. The resident's care plan specified the use of oxygen therapy, with a goal to remain free from adverse effects and interventions to provide oxygen as ordered, monitor oxygen saturation, and check the rate of oxygen flow every shift. The physician's order directed that oxygen be administered at 2 liters per minute (L/min) via nasal cannula, with titration up to 3 L/min if oxygen saturation fell below 92%. Despite these orders, observations on two separate occasions found the resident receiving oxygen at 3 L/min via nasal cannula, without documentation that the oxygen saturation was below 92% to warrant the increased flow. A registered nurse confirmed that the physician's order was for 2 L/min and acknowledged the risk of over-oxygenation. The facility's policy on medication reconciliation emphasized the importance of accurate medication dosages upon admission or readmission, but the resident was not administered oxygen according to the prescribed amount.
Incomplete and Inaccurate Documentation of Resident Services
Penalty
Summary
The facility failed to ensure that a resident's clinical record contained complete and accurate documentation of services not received, as required by its own policy and procedure on charting and documentation. Specifically, a resident with a history of traumatic brain injury, tracheostomy, ventilator dependence, and gastrostomy had physician orders for Restorative Nursing Assistant (RNA) program interventions, including the application of bilateral resting hand splints and bilateral knee extension splints. Documentation indicated that the resident received and tolerated these splints for specified periods; however, interviews and record reviews revealed that the resident was unable to tolerate the splints during certain dates, and this was not accurately documented in the medical record. RNA staff acknowledged that they did not write progress notes to reflect the resident's inability to tolerate the splints, despite being aware of the issue and notifying the Director of Rehabilitative Services (DOR) during an RNA meeting. The DOR confirmed that documentation should have accurately reflected the services provided and the resident's tolerance, and that oversight of RNA services and documentation accuracy was their responsibility. The facility's policy required objective, complete, and accurate documentation of treatments and resident tolerance, which was not followed in this instance.
Incomplete POLST Documentation for Incapacitated Resident
Penalty
Summary
The facility failed to complete the Physician Orders for Life-Sustaining Treatments (POLST) for one resident who was admitted with multiple serious medical conditions, including a stage 4 pressure ulcer, urinary tract infection, and a gastrostomy tube. The resident was documented as lacking capacity to make decisions and was assessed as having severely impaired cognitive skills, being totally dependent on staff for daily care. Despite this, the resident's POLST form was found to be incomplete, with critical sections such as Cardiopulmonary Resuscitation, Medical Interventions, Artificially Administered Nutrition, and Information and Signatures left unchecked. The form was also not signed by the resident's legally recognized decision maker, but only by the provider. During interviews, staff confirmed that the POLST was incomplete and acknowledged that all sections should be filled out as it is a legal document reflecting the resident's care preferences in emergencies. The facility's policy required that the provider speak with the resident or their legal representative to ensure the POLST accurately reflected the resident's wishes before signing. However, this process was not followed, and the responsibility for ensuring the POLST was complete was not met by the social worker and licensed nursing staff, as stated by the Director of Nursing.
Failure to Document Resident Hospital Transfer
Penalty
Summary
The facility failed to document the transfer of a resident to a general acute care hospital in the resident's medical records. The resident, who had chronic respiratory failure with hypoxia, a tracheostomy, and a gastrostomy tube, was noted to have severely impaired cognitive skills and was totally dependent on staff for daily activities. The physician had placed a telephone order for the transfer, but there was no documentation by facility staff regarding the resident's clinical condition, vital signs, or other pertinent information at the time of transfer. During a review, the Clinical Manager confirmed that the medical records were incomplete and not accurate, specifically lacking documentation of the transfer event. Facility policies required complete and accurate documentation of all services provided and any changes in the resident's condition, but these were not followed in this instance. The absence of documentation was identified through interviews and record reviews, highlighting a failure to maintain systematic and accessible medical records as per facility policy.
Failure to Develop Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple pressure ulcers, despite the resident's complex medical history and high level of dependency. Upon admission, the resident was diagnosed with several stage 4 and unstageable pressure ulcers, a urinary tract infection, and had a gastrostomy tube in place. The resident was also noted to have severely impaired cognitive skills and was totally dependent on staff for daily care activities. Although a baseline care plan was created at admission, no comprehensive care plan was developed more than two months later to address the resident's pressure ulcers. Interviews with facility staff confirmed that the comprehensive care plan, which should have been developed by the interdisciplinary team within 14 days of admission, was not completed. The Clinical Manager acknowledged the absence of a comprehensive care plan for the resident's wounds, and the Director of Nursing confirmed that the baseline care plan was only valid for 14 days. Facility policy required comprehensive care plans for skin alterations and pressure ulcers, with realistic, measurable goals and time frames for re-evaluation, but this was not followed in the resident's case.
Failure to Perform Weekly Pressure Ulcer Reassessment and Documentation
Penalty
Summary
The facility failed to ensure that a resident with multiple pressure ulcers received care in accordance with professional standards of practice. The resident, who was admitted with several Stage 4 and unstageable pressure ulcers and had severely impaired cognitive skills, was dependent on staff for all activities of daily living. The baseline care plan identified impaired skin integrity and required treatment as ordered, with monitoring for signs of infection. However, the weekly reassessment and documentation of the resident's pressure ulcers, including type, location, measurement, and description, were not completed as required. Specifically, the treatment nurse did not reassess or document the pressure ulcers on a scheduled weekly basis, as confirmed during an interview and record review. The facility's treatment nurse job description required maintaining and updating a pressure ulcer profile weekly, but did not specify reviewing and revising the care plan for accurate wound care guidance. Additionally, the facility's policy on pressure ulcers did not require scheduled weekly reassessment to determine progression. This lack of consistent and thorough reassessment and documentation increased the risk of the resident's pressure ulcers worsening or receiving inappropriate or delayed treatment, as the status and progression of the wounds were not adequately monitored.
Failure to Develop Comprehensive, Resident-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for one resident with significant care needs. The resident had multiple diagnoses, including a disorder of bone density, contractures at multiple sites, functional quadriplegia, and respiratory failure. Documentation showed the resident was totally dependent on staff for activities of daily living (ADLs) such as showering, dressing, oral hygiene, and personal hygiene, and lacked the capacity to understand or make decisions. Despite these needs, the care plan interventions were generic and did not specify critical details, such as the requirement for two-person assistance during care, nor did they provide measurable objectives or timetables tailored to the resident's condition. During interviews and record reviews, the DON acknowledged that the care plan was not person-centered and did not ensure the resident's needs were being met. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not reflected in the resident's care plan. The lack of specificity and individualized planning placed the resident at risk for injuries and unmet needs.
Failure to Provide Required Two-Person Assist During Resident Care
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living (ADLs) due to conditions such as functional quadriplegia, contractures, and cognitive impairment, was not provided the required two-person assist during care. The resident's care plan specifically indicated the need for two-person assistance with transfers, repositioning, and daily care due to their high risk for falls and injuries, as well as their inability to participate in or understand care activities. Despite this, a Certified Nursing Assistant (CNA) reported performing the resident's ADL care alone, including cleaning and turning, without assistance from another staff member. The Director of Nursing (DON) confirmed that the care plan required two-person assistance and acknowledged that failing to follow this intervention placed the resident at risk for further injuries. Facility policy emphasized the importance of safety, supervision, and targeted interventions to reduce individual risks, including communicating and assigning responsibility for specific interventions. The failure to provide the required two-person assist as outlined in the care plan and facility policy constituted the deficiency.
Infection Control and Food Safety Deficiencies
Penalty
Summary
The facility failed to implement its infection control program effectively, as evidenced by two key deficiencies. Firstly, a Laundry Aide (LA) was observed handling both dirty and clean linens without performing necessary hand hygiene or changing contaminated gloves and gown. This occurred after the LA sorted dirty linen and then proceeded to handle clean linen, which could lead to cross-contamination and infection. The Infection Prevention Nurse (IPN) confirmed that the LA should have changed her gown and gloves after handling the dirty linen to prevent the transfer of contaminants such as urine and feces to clean linen. The facility's policy and procedure on laundry processes also indicated that staff should wash hands after handling soiled linens to prevent cross-contamination. Secondly, the facility failed to refrigerate an opened food item as required, which involved a resident who had a bottle of strawberry jam on their bedside table. The label on the jam indicated it should be refrigerated after opening, but the facility did not have a refrigerator for storing residents' personal food items. A Licensed Vocational Nurse (LVN) observed the jam and acknowledged that not refrigerating it could lead to foodborne illnesses. The facility's policy discouraged food from outside sources due to food safety and infection control concerns. The resident involved had diagnoses including hyperlipidemia and hypertension, and was capable of understanding and making decisions, with no limitations to their extremities as per their assessment records.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of psychotropic medications to two residents. Resident 83 was administered lorazepam and sertraline without proper informed consent. The clinical records showed that lorazepam was given for anxiety over a period of 14 days, and sertraline was administered for depression. However, there was no documentation that Resident 83 or her responsible party received education regarding the risks and benefits of lorazepam before its administration. Informed consent for sertraline was obtained only after the medication had been initiated and subsequently discontinued. The Director of Nursing (DON) acknowledged the failure to obtain informed consent for Resident 83's medications, stating that this oversight increased the risk that the resident or her representative might not have been able to exercise their right to opt out of treatment. The facility's policy on psychotropic medications and informed consent requires that residents or their representatives be informed of the risks and alternatives before treatment, which was not adhered to in this case. Similarly, Resident 46 was prescribed duloxetine for peripheral neuropathy without documented informed consent. The resident's Minimum Data Set indicated the ability to express ideas and understand others, yet there was no consent form in the resident's chart. Both the RN and the Assistant Director of Nursing (ADON) confirmed the absence of informed consent documentation, which is required by the facility's policy before initiating treatment.
Failure to Ensure Windows Close Properly
Penalty
Summary
The facility failed to ensure that room windows were able to close properly in the rooms of three residents, resulting in the rooms being cold. During an initial tour, it was observed that the windows in the rooms of Residents 23, 55, and 102 were open and unable to be closed. Resident 102's window had a crack, and the windows in the rooms of Residents 23 and 55 were taped on three sides. Interviews with the residents revealed that they were aware of the issue and had to dress warmly to stay comfortable. Resident 102 reported the issue to a Certified Nursing Assistant, and a Maintenance Aide checked the window but was unable to fix it. The Maintenance Aide acknowledged the problem and stated that he had requested the windows to be replaced, but he was not qualified to do the replacement himself. The Administrator confirmed that a request for window replacement had been made and was awaiting a work order from the management company. The facility's policy on providing a homelike environment with comfortable temperatures was not adhered to, as the residents experienced cold conditions due to the inability to close the windows.
Deficiencies in Weight Monitoring and Blood Pressure Measurement
Penalty
Summary
The facility failed to ensure that a resident received weekly weight monitoring as ordered by the physician. The resident, who was admitted with conditions including hypotension, diabetes, and asthma, was dependent on staff for daily activities. The physician had ordered weekly weights for four weeks to manage the resident's weight, but the weights were only recorded on two occasions, missing the scheduled dates. This lack of monitoring meant that staff were unaware of any potential weight loss, which could have impacted the resident's health and dietary needs. Another deficiency involved the inaccurate measurement of orthostatic blood pressure for a resident with hypertension, muscle weakness, and bipolar disorder. The physician's order required monitoring for orthostatic hypotension, with specific instructions to notify the doctor if there was a significant drop in blood pressure readings between lying and sitting positions. However, the recorded blood pressures were identical for both positions, suggesting that the procedure was not followed correctly. The Director of Staff Development noted that the use of a manual blood pressure cuff might have led to rounding errors, preventing accurate assessment of the resident's condition. The facility's policies on weight assessment and blood pressure measurement were not adhered to, leading to these deficiencies. The policy required residents to be weighed at specified intervals and for blood pressure changes to be noted accurately. The failure to follow these procedures resulted in inadequate monitoring of the residents' health conditions, potentially delaying necessary interventions.
Improper Use of Pressure Relieving Devices
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set correctly for a resident with a Stage 4 pressure ulcer. The resident, who was small-framed and weighed less than 400 pounds, had a mattress set at 400 pounds, which was inappropriate for their weight. This incorrect setting could result in the mattress being too firm or too soft, thereby not promoting wound healing effectively. Interviews with the LVN, Wound Care Nurse, and DON confirmed that the incorrect setting would not be beneficial and could lead to slower healing or worsening of the pressure ulcer. Another deficiency was identified with a resident who was at risk for developing pressure injuries. The resident had a physician's order for Prevalon boots to offload pressure from the heels and prevent skin breakdown. However, during an observation, the resident was found without the boots, and the LVN present could not explain their intended use. The Director of Staff Development confirmed that the absence of the boots put the resident at risk for skin breakdown. These deficiencies highlight the facility's failure to adhere to care plans and physician orders, which are critical for managing and preventing pressure ulcers. The facility's policies on pressure injury prevention and wound care emphasize the importance of using appropriate supportive devices, yet these were not followed, placing residents at risk for further complications.
Deficiencies in ROM Care and RNA Services
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM) for six out of ten sampled residents. The deficiencies included not adhering to physician orders for the application and duration of splints, as well as failing to complete restorative nursing aide (RNA) treatments as prescribed. For instance, Resident 15 was observed wearing a right resting hand splint and a right elbow splint for longer than the physician-ordered four hours, which was confirmed by documentation showing the splints were applied for six hours on multiple occasions. Additionally, RNA treatments for Resident 15 were not completed on several specified dates. Resident 2 also did not receive RNA treatments as ordered, with documentation indicating missed sessions for PROM exercises and splint applications. Furthermore, Resident 2 did not receive timely annual Rehabilitation Joint Mobility Assessments (JMA) to monitor changes in joint ROM, with the last assessments being significantly outdated. Similar issues were noted for Resident 8, who did not receive timely annual JMAs, and Resident 24, who had ankle splints applied without a physician's order. Resident 24 also missed annual OT JMS, which are crucial for tracking and comparing joint ROM to identify any decline. Residents 17 and 67 experienced similar deficiencies, with RNA treatments not being completed as ordered. Resident 17's documentation showed missed RNA services for the application of hand rolls and elbow splints, while Resident 67's RNA task form indicated inconsistent application of a right PRAFO. Interviews with staff, including the Director of Nursing and the Director of Rehabilitation, highlighted the importance of following physician orders and completing RNA treatments to prevent worsening contractures and maintain joint mobility. The facility's policies and procedures emphasized the need for timely and appropriate RNA services, which were not adhered to in these cases.
Inadequate RNA Staffing Leads to Potential Decline in Resident Care
Penalty
Summary
The facility failed to provide adequate and sufficient nursing staff to meet the needs of residents requiring Restorative Nursing Aide (RNA) treatments. This deficiency was identified through observation, interviews, and record reviews, revealing that 81 residents with physician's orders for RNA services were at risk of experiencing a decline in range of motion, mobility, and activities of daily living function. The facility's staffing records for February and March 2025 showed inconsistencies in RNA staffing, with some days having no RNA staff available, leading to the reassignment of RNAs to Certified Nursing Assistant (CNA) duties. Interviews with RNA staff and the Director of Staff Development confirmed that RNAs were often reassigned to CNA duties due to a shortage of CNA staff, making it difficult for them to fulfill their RNA responsibilities. The Director of Nursing emphasized the importance of sufficient RNA staffing to ensure residents received their necessary treatments to prevent contractures and maintain joint mobility. The facility's policy on staffing indicated a commitment to providing sufficient nursing staff to meet residents' needs, but the observed staffing levels did not align with this policy.
Inadequate Competency in Assessing Orthostatic Hypotension
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVNs) possessed the necessary competencies to properly assess orthostatic hypotension in residents. During interviews, LVN 4 demonstrated a misunderstanding of the procedure by stating that if a resident's blood pressure in the lying position did not indicate hypotension, there was no need to take a sitting blood pressure reading. LVN 6 also showed a lack of understanding by indicating that blood pressure readings could be taken at the resident's convenience without a specific timeframe, contrary to the standard procedure. This misunderstanding of the procedure for assessing orthostatic hypotension could lead to a delay in care and services, potentially resulting in falls or injury to residents. The Director of Staff Development (DSD) clarified the correct procedure, which involves taking the resident's blood pressure in the lying position, then having the resident sit and waiting about five minutes before taking another reading. A change of 20 mmHg in the systolic or 10 mmHg in the diastolic value would indicate orthostatic hypotension, necessitating notification of the doctor for further orders. The facility's job description for LVNs requires them to ensure physicians' orders are followed and quality care is provided, highlighting the importance of proper training and understanding of procedures to prevent deficiencies in care.
Failure to Monitor Blood Pressure for Amlodipine Administration
Penalty
Summary
The facility failed to monitor the blood pressure of Resident 83 in relation to the administration of amlodipine, a medication used to treat high blood pressure, between March 23, 2024, and March 31, 2024. The resident's care plan, revised on March 27, 2024, indicated a risk for elevated blood pressure and required monitoring of pulse rate and blood pressure as ordered. Additionally, the care plan noted a risk of falls or injury related to antihypertensive medications, necessitating an assessment for possible adverse effects. Despite these directives, the Medication Administration Record (MAR) for March 2024 showed no documented blood pressure readings corresponding to the administration of amlodipine during the specified period. The Director of Nursing (DON) confirmed that the facility did not consistently document blood pressure readings in the MAR, which was necessary to adhere to the hold parameters specified in the physician's order for amlodipine. The facility's policy and procedure required obtaining and recording vital signs prior to medication administration, and the documentation of medication administration policy mandated the inclusion of specific medication parameters, such as blood pressure. The lack of documentation in the MAR made it impossible to determine if the medication was administered within the prescribed parameters, increasing the risk of adverse effects for the resident.
Failure to Appropriately Prescribe and Monitor Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was not prescribed Seroquel without an appropriate diagnosis. The resident was admitted with conditions such as hypotension, diabetes, and asthma, but there was no indication of a mental illness in their medical records. Despite this, an order was placed for Seroquel to be administered for psychosis, a diagnosis not supported by the resident's history or assessments. The facility's policy requires that psychotropic medications be prescribed only when necessary to treat a specific, documented condition, which was not adhered to in this case. Additionally, the facility did not adequately define and monitor behaviors related to the use of lorazepam for another resident. This resident, diagnosed with vascular dementia and anxiety, was prescribed lorazepam as needed for moderate anxiety. However, the facility failed to document or monitor the resident's behaviors during the administration of the medication, as required by their care plan and facility policy. The lack of monitoring meant that the effectiveness of the medication and the resident's response to it were not assessed. The Director of Nursing acknowledged the failure to monitor and define behaviors related to the use of lorazepam, which is crucial for assessing the medication's effectiveness and ensuring the resident's condition is adequately treated. The facility's policy emphasizes the importance of involving residents and their representatives in medication management and ensuring adequate monitoring for efficacy, which was not followed in these instances.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.06% due to two medication errors out of 33 opportunities. The errors affected two residents during medication administration. Resident 4 was prescribed a cranberry supplement at 425 mg but was administered a 450 mg dose. This discrepancy was observed when the Licensed Vocational Nurse (LVN 4) prepared and administered the incorrect dosage by crushing the tablet and mixing it with applesauce for the resident to consume. The error was acknowledged by LVN 4, who admitted to not clarifying the order with the physician to adjust for the available product strength. Resident 83 was prescribed a liquid formulation of multivitamins but was given a crushed tablet form instead. LVN 4 prepared and administered the incorrect formulation by mixing the crushed tablet with applesauce. During an interview, LVN 4 admitted to mistakenly believing the tablet and liquid formulations were interchangeable, not realizing the differences in formulation and strength. The facility's policy and procedure for medication administration emphasize adherence to physician orders and proper medication labeling, which were not followed in these instances.
Failure to Conduct Ordered Thyroid Panel for Resident
Penalty
Summary
The facility failed to ensure that a resident received the correct laboratory tests as ordered by the physician, which was necessary to monitor the resident's thyroid function due to the use of Seroquel, a medication for bipolar disorder. The resident's care plan indicated a risk for dehydration due to medication use, and the consultant pharmacist recommended a thyroid panel to assess thyroid function. However, the laboratory results showed that only a thyroid peroxidase and thyroglobulin antibody test was performed, rather than the complete thyroid panel that was ordered. During an interview, RN 2 confirmed that the thyroid panel was ordered but not conducted, and explained that the tests performed were not equivalent to a thyroid panel, which includes triiodothyronine (T3), thyroxine (T4), and thyroid stimulating hormone (TSH). This oversight could prevent the physician from identifying potential thyroid issues in the resident. The facility's policy required staff to process and arrange for tests as ordered by the physician, but this was not followed in this instance.
Failure to Follow Soft and Bite-Size Diet Menu
Penalty
Summary
The facility failed to ensure that the standardized recipes for the lunch menu were followed, specifically for residents on a soft and bite-size diet. On March 18, 2025, eighteen residents who required a soft and bite-size diet received whole bread instead of bread cut into smaller pieces, as per their dietary needs. The facility's lunch menu did not include the texture-modified diet that was ordered for these residents, and the menu lacked a serving guide for the bread at each meal. This discrepancy was observed during a kitchen inspection and interviews with the dietary staff, who admitted that the menu was still following old standards and had not yet transitioned to the new IDDSI standards, which the physician diet orders were based on. The Registered Dietitians and the Speech and Language Therapist confirmed that the facility was in the process of transitioning to the new IDDSI menu, but the current menu did not reflect the updated diet orders. The facility's diet manual, dated 2020, did not include a description or plan for a soft and bite-size diet, leading to inconsistencies between the diet orders and the menu. The facility's policies indicated that menus should be prepared using standardized recipes and that diet orders should align with the approved diet manual, which was not the case. This failure had the potential to result in meal dissatisfaction, decreased nutritional intake, and increased choking risk for the affected residents.
Unsanitary Can Opener Blade in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation practices in the kitchen, as observed during a survey. A can opener blade was found to be dirty, with a dry brown sticky residue, and worn out, which could potentially harbor harmful bacteria. The Dietary Supervisor confirmed the presence of the residue and was unable to identify its nature, although they suggested it could be removed with washing. The supervisor also admitted to not knowing when the blade was last cleaned. The facility's policy and procedure on sanitizing equipment and surfaces, which was undated, required that all equipment, shelves, serving utensils, and surface areas be clean and in good condition. Additionally, the 2022 U.S. Food and Drug Administration Food Code specified that can opener blades should be kept sharp to prevent metal fragments from contaminating food and that can openers must be replaced if they become uncleanable. This deficiency had the potential to result in harmful bacteria growth and cross-contamination, affecting 47 out of 109 residents who received food from the facility.
Deficiency in Policy for Storing Food Brought by Visitors
Penalty
Summary
The facility's policy on food brought in by family and visitors did not adequately address the storage and reheating of such food to ensure safe and sanitary conditions. The Dietary Supervisor stated that families are encouraged not to bring food that requires storage, as there is no space available for storing leftovers. The policy indicates that any leftover food will be discarded. Interviews with various staff members, including a charge nurse and treatment nurse, confirmed the absence of a refrigerator for residents to store perishable food. The Director of Nursing (DON) and the Administrator both acknowledged that the facility lacks a policy and procedure for safely storing food brought in from outside. The facility's policy titled 'Food From Outside Sources' discourages bringing in outside food due to concerns about food safety, infection control, and maintaining therapeutic diet orders. The policy states that the facility is not liable for food safety and infection control issues related to outside food, and any leftovers will be discarded. Despite this, there is no procedure in place for handling situations where residents or their families wish to store food for later consumption, potentially leading to foodborne illness among residents.
Failure to Obtain Consent and Order for Bed Rail Use
Penalty
Summary
The facility failed to ensure that Resident 99 was free from the use of physical restraints, specifically bed rails, without proper authorization and consent. During an observation, Resident 99 was found in bed with all four bed rails raised, which the resident did not request and did not recall any recent falls. The resident's Minimum Data Set indicated no limitations in range of motion, and the resident was capable of rolling left and right. However, there was no order for the use of bed rails, nor was there a signed informed consent for their use. The Assistant Director of Nursing confirmed that an assessment, consent, and order are required for the use of bed rails, which were absent in this case. The facility's policy defines a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. The policy also requires informing the resident or their representative about the risks and benefits of bed rails and obtaining informed consent before use. Despite these requirements, Resident 99's medical chart lacked the necessary documentation and orders for the use of bed rails, and the resident was found with all four side rails up, which is considered a restraint. This oversight had the potential to restrict the resident's movement and posed a risk of injury.
Failure to Document Diabetes Diagnosis on MDS
Penalty
Summary
The facility failed to ensure that a resident's diagnosis of diabetes mellitus (DM) was accurately entered on the Minimum Data Set (MDS), a critical assessment and care screening tool. The resident, who was admitted and readmitted with various diagnoses including polyneuropathy, hypertension, and fibromyalgia, was prescribed Metformin for DM as per a physician's order dated February 1, 2024. However, the MDS dated December 26, 2024, did not reflect the DM diagnosis, despite the resident's ability to express ideas and understand others. During an interview and record review on March 20, 2025, the MDS Coordinator acknowledged the absence of the DM diagnosis on the MDS, which is essential for accurate care planning. The facility's MDS Coordinator Job Description mandates the completion and auditing of all MDS entries for accuracy, yet this oversight occurred, potentially impacting the resident's care plan and the delivery of necessary services.
Unsafe Use of Extension Cords Poses Hazard
Penalty
Summary
The facility failed to ensure a safe environment for Resident 96 by allowing the use of an extension cord in a manner that posed a safety hazard. During an observation, it was noted that personal chargers were plugged into an extension cord that was lying on the ground next to the resident's bed and connected to another extension cord, which was also on the ground under the bed. This setup was identified as a potential fire and fall risk. Licensed Vocational Nurse (LVN) 3 acknowledged the hazard, stating that the extension cords should not be arranged in such a manner, as it posed a safety issue that could harm the resident. Further interviews with Maintenance Aide (MA) 1 and the Director of Nursing (DON) confirmed the unsafe nature of the extension cord setup. MA 1 indicated that the wrong type of extension cord was used and that it should not be plugged into another extension cord or placed on the ground. The DON also recognized the situation as a fall and fire hazard. The facility's policy on electrical safety, dated January 2011, specifies that extension cords should not be used as a substitute for adequate wiring and should be secured to prevent trips, falls, or overheating, and should only connect to one device.
Failure to Adhere to Medication Hold Parameters Leads to Resident Falls
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by administering amlodipine outside of the prescribed hold parameters. This occurred a total of 81 times over a period of several months, affecting a resident who was at risk for elevated blood pressure and falls due to the use of antihypertensive medications. The resident's care plan indicated a risk of falls and injury related to these medications, yet no specific interventions were in place to address this risk. The medication order specified that amlodipine should be held if the resident's systolic blood pressure was less than 120, but the medication was administered even when the blood pressure was below this threshold. As a result of this deficiency, the resident experienced two falls with injuries on specific dates, which were linked to the improper administration of the medication. The Director of Nursing acknowledged that the licensed staff failed to observe the hold parameters, potentially contributing to the resident's falls and injuries. The facility's policies and procedures for medication administration were not followed, as medications are required to be administered according to the physician's written orders. The facility's clinical protocol for hypertension also emphasized the importance of monitoring for complications such as dizziness and falls, which were not adequately addressed in this case.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control measures for two residents. For Resident 2, the facility did not ensure that the foley catheter bag was kept off the floor, which is crucial to prevent urinary tract infections. Additionally, Licensed Vocational Nurses (LVNs) 1 and 2 did not wear the required Personal Protective Equipment (PPE) while providing wound care to Resident 2, who was on Enhanced Barrier Precautions due to the risk of transmitting Multidrug-Resistant Organisms. LVN 1 also failed to perform hand hygiene during wound care after cleaning stool and between glove changes. Resident 2 was admitted with diagnoses including a Stage 4 pressure ulcer, unspecified dementia, and cellulitis. The resident was totally dependent on staff for activities of daily living and had a physician's order for specific wound treatment. During an observation, the foley catheter bag was seen on the floor, and LVNs entered the room without donning isolation gowns, despite the presence of an Enhanced Barrier Precautions sign. LVN 1 cleaned stool and the wound without changing gloves or performing hand hygiene, which was confirmed as a breach of protocol by RN 1. For Resident 3, who was admitted with a Stage 4 pressure ulcer and other conditions, LVN 1 was observed performing wound care without performing hand hygiene between glove changes. This was acknowledged by LVN 1 and RN 1 as a failure to follow infection control practices. The facility's policies on hand hygiene, catheter care, and Enhanced Barrier Precautions were reviewed, indicating the importance of these measures in preventing the spread of infections.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents, leading to unsanitary living conditions. Resident 2, who was admitted with a Stage 4 pressure ulcer, unspecified dementia, and cellulitis, was found to be totally dependent on staff for activities of daily living. Observations in Resident 2's room revealed multiple dry brown spots on the ceiling, peeling paint, and black dirt in the corners of the walls and floor. Resident 4, who was diagnosed with COPD, hemiplegia, hemiparesis, and schizophrenia, was also totally dependent on staff for daily activities. Similar observations were made in Resident 4's room, with multiple dry brown spots on the ceiling. Interviews with facility staff, including a CNA and the Maintenance Supervisor, confirmed the presence of these deficiencies. The CNA acknowledged seeing the ceiling stains but was unsure of their origin, while the Maintenance Supervisor admitted to not noticing the stains during his rounds and acknowledged the need for maintenance and cleaning. The Registered Nurse emphasized the importance of daily room checks and maintenance to ensure a homelike environment. The facility's policies and procedures highlighted the need for a clean, sanitary, and orderly environment, which was not upheld in this instance.
Failure to Provide Clean Bed Sheets for a Resident
Penalty
Summary
The facility failed to provide a clean and homelike environment for one of the residents, identified as Resident 2, by not ensuring clean bed sheets were used. During an observation, it was noted that Resident 2's bed had brown dry spots on the bottom sheet, yellow stains on the top sheet, and a white blanket with brown spots. Despite these visible stains, the Certified Nurse Assistant (CNA) did not change the bottom sheet after providing a bed bath and covered the resident with the stained top sheet and blanket. The CNA acknowledged that the sheets were stained and stated that bed sheets are supposed to be changed daily if soiled or dirty. Resident 2, who was admitted to the facility with a gastrostomy tube and anoxic brain damage, was dependent on staff for activities of daily living (ADL) care due to cognitive and functional deficits. Interviews with other staff, including another CNA, a Registered Nurse (RN), and the Director of Nursing (DON), confirmed that the facility's policy requires bed sheets to be changed daily and as needed when soiled. The staff emphasized the importance of maintaining a clean environment to prevent infection and uphold the resident's right to a clean living space. The facility's policy and procedures also highlighted the need to provide a safe, clean, and comfortable environment with clean linen for residents.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the California Department of Public Health (CDPH) within the required two-hour timeframe as per their policy. The resident, who was admitted with conditions such as hemiplegia, dysphagia, and severe cognitive impairment, was found to have a yellowish-green skin discoloration on the left wrist. This discoloration was first noticed by a family member on July 30, 2024, and reported to the facility on August 2, 2024. However, the facility did not document this report in the progress notes or create a Change of Condition (COC) assessment on the same day. The facility eventually faxed the Report of Suspected Dependent Adult/Elder Abuse to the CDPH on August 3, 2024, which was beyond the two-hour reporting requirement. Interviews with family members and staff revealed that the discoloration was indicative of potential abuse, and the delay in reporting was acknowledged by the Director of Nursing. The failure to report the incident in a timely manner resulted in a delayed investigation by the CDPH and placed the resident at risk for further abuse.
Failure to Provide Timely Toileting Hygiene
Penalty
Summary
The facility failed to provide timely toileting hygiene for a resident who was dependent on staff for assistance. The resident, who had severe cognitive impairment and was diagnosed with conditions such as hemiplegia, hemiparalysis, dysphagia, and osteoarthritis, was not changed for at least 30 minutes after becoming combative during toileting hygiene. A Certified Nurse Assistant (CNA) attempted to change the resident but stopped due to the resident's combative behavior. The resident's family member eventually assisted in changing the resident. The Director of Nursing (DON) confirmed there was no documentation of the resident refusing care and stated that the CNA should not have waited for the family member to assist. The facility's policy and procedures for perineal care emphasize the importance of cleanliness, comfort, and skin condition observation, and require notifying the charge nurse if a resident refuses care. The delay in providing care had the potential to cause skin breakdown, as acknowledged by both the CNA and the DON.
Infection Control Deficiencies in Oxygen and GT Site Management
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by the improper storage of oxygen nasal cannulas for two residents. Both residents were observed with their oxygen concentrators turned on, but the nasal cannulas were not in use and were hanging uncovered on gastrostomy tube (GT) feeding poles. This practice was contrary to the facility's policy, which required that unused oxygen tubing be stored in a clean bag with the resident's name and room number to prevent contamination. Interviews with staff, including a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN), confirmed that the nasal cannulas should not have been left uncovered and in contact with surfaces, as this could lead to contamination and potential infection. Additionally, the facility failed to maintain cleanliness at the gastrostomy tube sites for two other residents. Observations revealed that one resident's GT site had no dressing and showed signs of dried serous sanguineous spots and redness, while another resident's GT dressing had dried brownish spots. The LVN acknowledged that the GT sites were dirty and should have been cleaned, emphasizing the risk of infection and skin breakdown if not properly maintained. The Director of Nursing (DON) stated that GT dressings should be changed daily or as needed when dirty, and licensed staff could change the dressings during rounds and medication passes. The facility's policy on gastrostomy/jejunostomy tube site care, dated March 2023, outlined the importance of promoting cleanliness and protecting the site from irritation, breakdown, and infection. It required cleaning the area surrounding the tube, assessing the stoma site for signs of infection, and reporting any signs of infection to the resident's physician. The failure to adhere to these policies and procedures resulted in deficiencies that had the potential to cause infections in the affected residents.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to promptly notify the physician of a change of condition for a resident who was observed with slurred speech, a potential symptom of a stroke. The resident, who had a history of cerebral infarction and other related conditions, was noted to have an altered level of consciousness and weakness on the right side. Despite these symptoms, the Licensed Vocational Nurse (LVN) did not notify the physician, as the resident was still responsive. The Director of Nursing (DON) later confirmed that the resident's slurred speech was a change of condition that should have been reported to the physician. The resident was eventually taken to a General Acute Care Hospital, where they were diagnosed with an acute subdural hematoma. Interviews with staff revealed that the resident exhibited signs of a stroke, such as slurred speech and a steady gaze, which were not reported to the physician in a timely manner. The facility's policy and procedures require that any change of condition be promptly reported to a physician, which was not followed in this case, resulting in delayed medical care for the resident.
Failure to Identify and Respond to Change of Condition
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) had the necessary competencies to identify and respond to a change of condition (COC) in a resident. The resident, who had a history of hemiplegia, hemiparesis, and other serious conditions following a stroke, experienced an altered level of consciousness and weakness in the right arm. Despite these symptoms, the LVN did not notify the physician or the Registered Nurse (RN) on duty, as required by the facility's policy. The LVN observed the resident with impaired speech and a steady gaze but did not recognize these as potential signs of a stroke, leading to a delay in care. Interviews with the RN and the Director of Nursing (DON) revealed that the LVN did not report the resident's slurred speech and other symptoms, which were not part of the resident's baseline condition. The DON emphasized that such symptoms should have been reported immediately to the physician for further assessment and possible hospital transfer. The facility's policy clearly stated that changes in a resident's condition, such as altered level of consciousness and confusion, should be documented and reported promptly, which the LVN failed to do, resulting in a potential risk of harm to the resident.
Failure to Follow Physician's Order for Midodrine Administration
Penalty
Summary
The facility failed to adhere to the physician's order regarding the administration of Midodrine, a medication used to treat low blood pressure, for a resident. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and hypotension, had an order to receive Midodrine 10 mg via gastric tube every 8 hours, with instructions to hold the medication if the systolic blood pressure (SBP) exceeded 110 mmHg. However, the Medication Administration Record (MAR) for July 2024 showed that the medication was administered on three occasions when the resident's SBP was above the specified threshold: 115 mmHg on July 4th, 114 mmHg on July 5th, and 116 mmHg on July 6th. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the medication was not held as per the physician's order. The DON acknowledged that the failure to hold the medication could lead to increased blood pressure and potential complications. The facility's policy and procedure on medication administration, dated April 2008, emphasized that medications should be administered as prescribed and in accordance with good nursing principles, which was not followed in this instance.
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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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