Whittier Pacific Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Whittier, California.
- Location
- 7716 S Pickering Avenue, Whittier, California 90602
- CMS Provider Number
- 055764
- Inspections on file
- 49
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Whittier Pacific Care Center during CMS and state inspections, most recent first.
A resident with contractures, muscle weakness, and impaired decision-making capacity had physician orders and care plans directing that a low air loss mattress (LALM) be set according to current weight for wound management and pressure ulcer prevention. The resident weighed 88 lbs, but during surveyor observation the LALM was found set at 120 lbs, despite nursing staff and the DON acknowledging it should be set lower than the resident’s weight (around 80 lbs) to allow proper pressure redistribution. The resident subsequently experienced a change in skin condition with reopening of fragile scar tissue and development of an in-house acquired Stage 1 pressure injury on the right trochanter, even though facility policy and the LALM manual required adjustment of the support surface based on the patient’s weight and care plan.
A resident with bilateral nephrostomy tubes, anoxic brain damage, and a persistent vegetative state experienced multiple episodes of nephrostomy tube malfunction and dislodgement associated with UTIs, each requiring hospital evaluation and tube exchange. The existing care plan only addressed securing the tubing with anchors and was not revised with new, individualized interventions despite repeated dislodgements, hospitalizations, and documentation of empty drainage bags, displaced tubing, and saturated dressings. Nursing staff and the DON acknowledged that the care plan was not updated and that no IDT meeting or root cause analysis was conducted to determine why the nephrostomy tubes continued to become dislodged, contrary to facility policy requiring ongoing assessment and care plan revision when outcomes are not met and after hospital readmissions.
A resident with severe cognitive impairment and a Foley catheter was observed with an uncovered urinary drainage bag, exposing its contents. Facility staff, including an LVN, DSD, and DON, confirmed that the bag should have been covered to maintain dignity, as required by facility policy. This failure violated the resident's right to be treated with dignity and respect.
The facility posted inaccurate CNA staffing information for the overnight shift, listing more CNAs and hours than were actually present according to sign-in sheets. Both the DSD and DON confirmed the discrepancy, acknowledging that the posted data did not match actual staffing records and could mislead residents and visitors.
The facility failed to keep two outdoor refuse containers closed with tight-fitting lids, as observed during an interview with the Dietary Supervisor. The containers were open, full, and overflowing, with one propped open by a red stick. The Maintenance Supervisor explained that staff used the stick to keep the lid open due to the height of the containers, but forgot to remove it. The facility's policy requires containers to be covered when not in use.
The facility failed to provide consistent restorative nursing care for four residents, leading to missed RNA services and exercises as ordered by physicians. Observations and interviews revealed that residents were often without necessary supports, and documentation confirmed missed sessions. Staffing shortages and transcription errors contributed to the deficiencies.
The facility failed to provide sufficient staffing for Restorative Nursing Assistant (RNA) services, leading to residents with limited range of motion not receiving prescribed exercises. RNA staff were often reassigned to Certified Nursing Assistant (CNA) duties due to staffing shortages, resulting in missed RNA sessions. Interviews with staff confirmed the issue, and the facility's staffing policy was not adhered to, causing a deficiency in care.
A facility failed to maintain a medication error rate below five percent when an LVN did not flush a G-Tube between administering medications to a resident, resulting in a 33.3% error rate. The resident, with a history of metabolic encephalopathy and sepsis, was dependent on staff for daily activities. The LVN admitted the error, and the ADON confirmed the correct procedure, highlighting the importance of flushing to prevent medication errors.
The facility's QAA committee failed to effectively identify and monitor a deficiency related to insufficient RNA staffing, affecting 19 residents who required RNA services to prevent mobility decline. The Administrator and DON were unaware of ongoing issues, such as RNAs being reassigned to CNA tasks and incorrect transcription of physician orders in the EMR system. This lack of oversight and ineffective QAPI processes contributed to the deficiency not being addressed.
The facility failed to adhere to infection control policies, resulting in deficiencies involving five residents. A resident's catheter bag and another's feeding tubing were found on the floor, posing contamination risks. A CNA did not perform hand hygiene between resident care, and family members of a resident did not follow Enhanced Barrier Precautions, increasing the risk of infection spread.
The facility failed to offer and provide information on Advance Directives to two residents during their admission and re-admission. One resident, with conditions including ventilator dependence and epilepsy, had no advance directive noted in their POLST form. Another resident, with muscular dystrophy and quadriplegia, had no signed Advance Healthcare Directive Acknowledgement form, despite discussions with Social Services. The absence of these directives was confirmed by facility staff.
A facility failed to transmit a resident's Discharge MDS to CMS within the required 30-day period. The resident, who had multiple diagnoses including metabolic encephalopathy and heart failure, was discharged to an Assisted Living Facility. The MDS Nurse admitted to forgetting to complete the discharge MDS, and the DON highlighted the importance of timely submissions for accurate reporting.
A facility failed to follow professional standards for G-Tube medication administration for a resident by not checking gastric residuals and not flushing the tube with water between medications. The resident, with severe cognitive impairment and multiple diagnoses, was at risk due to these oversights. The facility's policy requires flushing with water and checking residuals to prevent complications.
A resident at high risk for falls, with conditions including spinal stenosis and lack of coordination, fell over a wet floor sign while attempting to use the restroom unassisted. Despite requiring partial assistance for daily activities and having a history of falls, the facility did not initiate a bowel and bladder training program. Staff confirmed the oversight, acknowledging the need for such a program to prevent unassisted attempts to use the restroom.
A resident with a high risk for falls fell over a Wet Floor sign placed in front of their room, highlighting inadequate supervision and safety measures. The resident, with a history of falls and unsteady gait, was not monitored at the time of the incident, and the placement of the sign created a hazard. The facility's policy on maintaining a safe environment was not followed.
A resident with an indwelling Foley catheter for wound care management was not provided appropriate care, as the catheter was not properly secured and had sediment in the urine, indicating a possible UTI. The facility failed to document urine characteristics and did not report the sediment to a physician, contrary to its policies.
A facility failed to use appropriate alternative interventions before installing side rails for a resident with acute respiratory failure and hemiplegia. The resident's informed consent was incomplete, and there was no evidence of alternative measures being attempted. Staff interviews revealed a practice of automatically using side rails without documented alternatives, contrary to facility policy.
The facility failed to ensure that an LVN and a CNA completed their annual competency assessments, with lapses noted in 2024. The DON and DSD were unaware of the reasons for these omissions, despite facility policy requiring annual evaluations.
A facility failed to provide required specialized rehabilitation services for a resident by not conducting annual and quarterly joint mobility assessments. The resident, with conditions including hemiplegia and diabetes, had not received an OT joint mobility screening since 2022, and no PT or OT screenings were documented for 2024. The Director of Rehab acknowledged the oversight, and the DON highlighted the importance of these assessments in preventing contractures and maintaining independence.
A facility failed to explain an arbitration agreement to a resident's responsible party, who was unable to make an informed decision about the resident's care. The responsible party, who signed the document without understanding it, reported that the forms were handed over without explanation. The Admissions Coordinator stated the document was self-explanatory, while the Administrator acknowledged the need for proper explanation as per regulations.
A facility failed to maintain a functioning call light system for three residents, including one with Alzheimer's and another with hemiplegia. Despite pressing the call lights, the system did not signal at the nurse's station or outside the rooms. The issue was confirmed by the ADON and IPN, and the Maintenance Supervisor noted the malfunction had not been reported, despite daily checks.
The facility was found deficient in providing adequate room size, with 11 rooms measuring less than the required 80 square feet per resident. Despite this, residents and staff reported no adverse effects on care or mobility, as adjustments were made to accommodate space needs.
The facility failed to respond to call lights in a timely manner for four residents, leading to delays in assistance for personal hygiene and other needs. Residents reported waiting 1-2 hours for help, contrary to the facility's policy of responding within five minutes. This delay increased the risk of harm and discomfort for the residents.
A resident with acute respiratory failure and cerebral aneurysm was not properly offered the influenza vaccine, and the facility failed to provide necessary education or document the refusal with the required signature. The resident denied refusing the vaccine, contradicting the LVN's account. The facility's policy requires informed consent and documentation, which was not adhered to in this instance.
A resident with acute respiratory failure and cerebral aneurysm was not offered the Covid-19 vaccine, nor educated on its benefits and risks, contrary to facility policy. The resident's refusal was not properly documented, leading to a deficiency. Interviews revealed inconsistencies in the vaccine offer process, with the resident denying refusal and lack of informed consent.
A resident with severe cognitive impairment expressed discomfort with a male CNA providing pericare, but the facility failed to investigate or report the incident as required. The resident's preference for female CNAs was not reflected in staffing assignments, leading to the same male CNA being assigned again, causing the resident to feel unsafe. Communication breakdowns and non-adherence to abuse prevention policies were evident among facility staff.
A resident's rosary was lost due to the facility's failure to document it on the inventory list, despite being acknowledged by staff. The resident, with severe cognitive impairment, received the rosary from a priest, but it was not listed when the resident was transferred to another care unit. Interviews with staff revealed that the facility's policy required documentation of new items, but items from church services were not typically recorded, leading to the oversight.
A resident with severe cognitive impairment and anoxic brain damage did not receive a recommended dental x-ray due to a communication breakdown among staff. The dentist's recommendation was missed, and the facility's policy requiring social services to obtain needed services was not followed, potentially causing the resident to experience pain.
The facility failed to follow its infection prevention and control practices in handling dirty linens, affecting six residents. Isolation linens were not double-bagged or labeled, leading to potential cross-contamination. Interviews revealed discrepancies between staff practices and facility policies, increasing the risk of infection spread.
A resident with cognitive impairment fell from a shower chair, and the facility failed to notify the physician or responsible party. The ADON was unaware of the incident until two weeks later, and no documentation of required assessments or notifications was found, contrary to the facility's policy.
A facility failed to update care plans for two residents, one with a history of falls and another with behavioral issues. The first resident's fall was not documented, and their care plan was not revised to prevent future incidents. The second resident's disruptive behavior was not addressed in their care plan, leading to unawareness among staff about monitoring needs. These deficiencies highlight a lack of documentation and communication in care planning.
Two residents with pressure ulcers received inadequate care due to the use of rough, reusable washcloths instead of disposable wipes, as required by the facility's policy. The facility's insufficient supply of disposable wipes contributed to this issue, potentially hindering wound healing and causing discomfort.
A resident with a history of falls experienced a recurrent fall due to inadequate supervision and lack of intervention. The resident, diagnosed with muscle weakness, osteoarthritis, and dementia, fell after standing from a shower chair without shoes. The incident was not documented or investigated, and the facility's fall protocol was not followed, resulting in a deficiency in care and supervision.
The facility failed to provide adequate staffing for RNA services, leading to a resident not receiving prescribed exercises for two months. CNAs were assigned RNA duties without proper scheduling, affecting 19 residents. The facility lacked a clear list of residents in the RNA program, resulting in inconsistent care.
The facility did not update and post daily staffing information in a visible location, as required. On a specific day, the staffing information was outdated, showing data from several days prior. A last-minute change in RN staffing assignments led to the delay in updating the posting. The facility's policy mandates that direct care daily staffing numbers be posted for every shift, which was not followed, resulting in this deficiency.
A resident with diabetes and a below-knee amputation did not receive accurate documentation of RNA-assisted exercises due to a Restorative Nurse Assistant (RNA) documenting care she did not provide. The RNA admitted to documenting exercises at the request of a CNA, despite not being on duty. Facility records confirmed the RNA's absence, and interviews with staff highlighted that this practice was against facility policy.
A resident with a history of self-decannulation removed their tracheostomy tube multiple times, but the facility failed to notify the physician and family on one occasion. Despite having a care plan that required notification, the incident was not documented, and the physician and family were not informed. Interviews confirmed the oversight, highlighting a deficiency in the facility's care practices.
A facility failed to update a care plan for a resident with a tracheostomy who had a history of self-decannulation. Despite the resident's impaired cognition and physician's orders to monitor anxiety and use interventions like Ativan and a freedom splint, the care plan was not updated after three self-decannulation incidents. The Director of Nursing acknowledged the lack of documentation and the need for updated interventions, highlighting the facility's failure to adhere to their policy for comprehensive, person-centered care plans.
A resident with a G-tube was observed without an abdominal binder, contrary to physician orders, due to the binder being laundered and no spare available. The resident, with severe cognitive impairment and multiple medical conditions, required the binder to prevent G-tube dislodgement, as outlined in their care plan.
The facility failed to document the rationale for extending PRN psychotropic medications for two residents, as required by policy. One resident was prescribed Valium for anxiety, and another was prescribed Lorazepam for anxiety, both without documented justification for continued use beyond 14 days. The Director of Nursing confirmed the absence of necessary documentation from the prescribing physicians.
The facility failed to investigate and resolve a grievance regarding a missing specialized wheelchair for a resident with chronic respiratory failure and quadriplegia. Despite the resident's representative's complaints, the facility did not document or address the issue promptly, contrary to its policies and procedures.
The facility failed to update and revise the care plans for two residents. One resident's care plan was not updated to reflect isolation requirements after testing positive for CRAB, and another resident's care plan did not include specific music preferences despite being identified. Both residents had severe impairments and were dependent on others for all activities of daily living.
Improper Low Air Loss Mattress Setting Leads to Trochanter Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a low air loss mattress (LALM) was set according to a resident’s weight as ordered and care planned, resulting in an alteration in skin and reopening of fragile scar tissue on the right trochanter. The resident was initially admitted with diagnoses including sepsis, bilateral knee contractures, and muscle weakness, and a history and physical documented that the resident lacked capacity to understand and make decisions. Physician orders and active care plans for alteration in skin integrity and risk for pressure ulcers directed that the LALM be set according to the resident’s weight for wound management and pressure redistribution. Record review showed that the resident’s weight was 88 lbs, and the Treatment Administration Record for the month indicated that on one day shift the LALM was documented as set according to the resident’s weight. However, during observation in the resident’s room, surveyors found the LALM set at 120 lbs rather than at or below the resident’s current weight. Treatment nurses interviewed at the time of observation stated that the LALM setting should be based on the resident’s weight, that settings higher than the resident’s weight make the mattress firmer, and that for this resident a setting of 80 would have been appropriate, while 120 could be too firm. The DON similarly stated that the resident’s weight should always be higher than the LALM setting and that a higher setting could defeat pressure redistribution and potentially increase pressure on the skin. A change-of-condition assessment documented that the resident was noted with a change in skin condition during routine treatment, with the right trochanter area observed to be reopened at the site of previous fragile scar tissue, described as a small open area with minimal drainage and fragile surrounding skin. A subsequent skin issues document identified an in-house acquired Stage 1 pressure ulcer/injury on the rear right trochanter, with specific measurements and wound characteristics recorded. The facility’s policy on support surfaces directed staff to review the care plan and use redistributing support surfaces to prevent skin breakdown and provide pressure relief or reduction, and the LALM operator’s manual indicated that the mattress should be adjusted according to the patient’s weight or a health care professional’s suggestion. Despite these directives, the LALM was not maintained at a setting consistent with the resident’s weight and care plan interventions.
Failure to Revise Care Plan and Perform IDT Root Cause Analysis for Recurrent Nephrostomy Tube Dislodgement
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise a comprehensive, individualized care plan addressing recurrent nephrostomy tube dislodgement for a resident with bilateral nephrostomy tubes and complex medical conditions. The resident had diagnoses including anoxic brain damage, persistent vegetative state, artificial openings of the urinary tract (nephrostomy tubes), pyelonephritis, urinary calculi, and UTI. On admission and subsequent review, the care plan identified an alteration in urinary elimination and risk for UTI related to indwelling catheters (nephrostomy tubes), with an intervention to secure the left and right nephrostomy tubing with anchors each shift to minimize dislodgement. Despite this, the resident experienced multiple episodes of nephrostomy tube malfunction and dislodgement requiring hospital evaluation and tube exchanges. On one occasion, facility records and GACH documentation showed the resident was admitted with percutaneous nephrostomy malfunction and UTI, underwent right and left nephrostomy tube exchange, received antibiotics, and was then readmitted to the facility. Later, a Change of Condition note documented that the treatment nurse notified an RN that the resident’s right nephrostomy tube was dislodged, with hematuria noted in the left nephrostomy bag, and the resident was again sent to the hospital, where records indicated admission for UTI and dislodged right nephrostomy tube and a right nephrostomy tube exchange with IV antibiotics. Subsequent Change of Condition documentation described a CNA reporting that the left nephrostomy tube appeared out of place, the urine collection bag was empty, and the gauze dressing used to keep the tube in place was off and saturated with urine. The RN observed the nephrostomy tube inside the stoma but 13.5 cm out with urine leaking from the stoma, and the physician was notified with a request to transfer the resident for replacement. Further documentation showed another Change of Condition entry noting no urine output in the left nephrostomy bag and a new order from the physician to send the resident to the hospital for exchange. GACH records indicated the resident had multiple dislodged nephrostomies over the past few months, was paraplegic and bedbound, and had been seen at another hospital two to three days earlier for similar issues, with a subsequent left nephrostomy tube placement and antibiotics. Interviews with RN staff and the DON confirmed that, despite these recurring dislodgements, the care plan was not revised to include new or individualized interventions to prevent further nephrostomy tube dislodgement. RN 2 acknowledged that the care plan had not been updated with new interventions and stated it was important to keep the care plan updated. The DON stated that the IDT did not hold a meeting regarding the recurring nephrostomy tube dislodgements, that a root cause analysis was not done, and that it was never determined why the nephrostomy tubes continued to become dislodged, despite facility policy requiring ongoing assessment, IDT review, and care plan revision when desired outcomes are not met or after hospital readmissions. The facility’s written policy on comprehensive person-centered care plans stated that the IDT, in conjunction with the resident and representative, develops and implements a comprehensive care plan derived from thorough assessment, reflecting recognized standards of practice, and addressing underlying causes of problem areas. The policy further required that assessments be ongoing and care plans revised as residents’ conditions change, with IDT review and updates when there is a significant change in condition, when desired outcomes are not met, and when a resident is readmitted from a hospital stay. In this case, despite multiple nephrostomy tube dislodgements, repeated hospital admissions for nephrostomy malfunction and UTI, and documentation from hospital providers noting multiple dislodgements over months, the facility did not conduct an IDT meeting, did not perform a root cause analysis, and did not revise the resident’s care plan with individualized, preventative interventions specific to nephrostomy tube dislodgement.
Uncovered Foley Catheter Bag Violates Resident Dignity
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, dementia, benign prostatic hyperplasia, and acute kidney failure was observed with an uncovered Foley catheter urinary drainage bag. The resident required significant assistance with daily activities and had a Foley catheter in place for urinary retention. During an observation, the urinary drainage bag was visibly exposed, showing yellow urine, and was not covered as required by facility policy. Interviews with facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, confirmed that the urinary drainage bag should have been covered to protect the resident's dignity, in accordance with facility policy and procedures. Review of the facility's policies further indicated that all residents are to be treated with dignity and respect, and that staff are expected to help residents keep urinary catheter bags covered. The failure to cover the urinary drainage bag constituted a violation of the resident's right to dignity and respect.
Inaccurate Posting of CNA Staffing Information
Penalty
Summary
The facility failed to ensure the accuracy of nurse staffing information posted daily, specifically regarding the number of certified nurse assistants (CNAs) working the 11 PM to 7 AM shift on several dates. The Daily Skilled Nursing Facility (SNF) Staffing Posting indicated that four CNAs worked these shifts, totaling 32 hours, while a review of the Nursing Staffing Assignment and Sign-In Sheets showed that only three CNAs actually worked, totaling 24 hours. This discrepancy was confirmed during interviews with both the Director of Staff Development (DSD) and the Director of Nurses (DON), who acknowledged that the posted information was inaccurate and did not reflect the actual staffing levels for those shifts. The facility's policy required accurate daily posting of nurse staffing data, including the number and type of nursing personnel providing direct care, to be displayed in a prominent location accessible to residents and visitors. The inaccurate postings had the potential to misinform residents and visitors about the actual number of CNAs available to provide care during the affected shifts. The DSD, who was responsible for completing the staff posting, and the DON both recognized that the posted information did not match the actual staffing records for the specified dates.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that two of four outdoor refuse containers were closed with tight-fitting lids and kept covered. During an observation and interview with the Dietary Supervisor, it was noted that the refuse containers were open, full, and overflowing with closed plastic bags of garbage hanging outside. One container had a red stick propping the lid open. The Dietary Supervisor acknowledged that the lids should be closed at all times. In a subsequent observation and interview with the Maintenance Supervisor, the red stick was removed, and the container was closed. The Maintenance Supervisor explained that the refuse containers' openings were too high for some staff, leading them to use the red stick to keep the lid open, but they forgot to remove it afterward. The facility's policy, dated October 2017, requires all garbage and refuse containers to have tight-fitting lids and be kept covered when not in continuous use.
Failure to Provide Consistent Restorative Nursing Care
Penalty
Summary
The facility failed to provide restorative nursing care, treatments, and services to minimize decline in joint range of motion (ROM) for four residents. These residents were ordered by their physicians to receive Restorative Nursing Assistant (RNA) assisted exercises and services. However, the facility did not ensure that these services were consistently provided as ordered. For instance, Resident 30 did not receive RNA services on multiple specified dates, and observations showed that the resident was often without the prescribed ankle-foot orthosis (AFO) and knee splints. The responsible party expressed concerns about the resident's condition deteriorating due to lack of proper care. Resident 70's physician order was inaccurately transcribed, leading to the resident receiving RNA services only three times a week instead of the ordered five times. Observations confirmed that the resident was not receiving the necessary exercises and AFO application as frequently as required. The RNA staff confirmed that the transcription error led to the resident not being scheduled for the correct number of sessions, and staffing shortages further exacerbated the issue. Resident 72 and Resident 14 also experienced similar deficiencies, with RNA services not being provided as frequently as ordered. Observations and interviews revealed that these residents were often without necessary splints and supports, and the documentation confirmed missed sessions. The facility's staffing issues, where RNAs were reassigned to CNA duties, contributed significantly to the failure in providing consistent restorative care. The Director of Staff Development and other staff acknowledged the scheduling and documentation issues, which led to residents missing essential RNA programs.
Insufficient Staffing for RNA Services
Penalty
Summary
The facility failed to ensure sufficient staffing to perform Restorative Nursing Assistant (RNA) services and exercises as ordered by physicians for residents with limited range of motion (ROM). On multiple occasions, RNA staff were reassigned to perform Certified Nursing Assistant (CNA) duties due to insufficient CNA staffing, resulting in residents not receiving their prescribed RNA programs. This deficiency was observed through a review of the facility's Daily Staffing Assignments, which showed that on several dates, either no RNA was assigned, or RNAs were reassigned to CNA duties, leaving residents without the necessary RNA services. Interviews with RNA staff and the Director of Staff Development (DSD) confirmed that when the facility was short-staffed, RNAs were often pulled to cover CNA duties. This led to situations where residents did not receive their RNA programs, as RNAs did not work overtime to cover the missed sessions. The DSD acknowledged the importance of having two RNAs scheduled daily to ensure all residents receive their RNA treatments, but admitted that finding coverage was sometimes challenging. The Assistant Director of Nursing (ADON) and the Director of Rehab (DR) also emphasized the importance of having sufficient RNA staff to prevent contractures and improve residents' mobility. The facility's policy on staffing, dated August 2022, indicated that sufficient numbers of nursing staff should be provided to meet residents' needs, but the observed staffing practices did not align with this policy, leading to the deficiency in care for residents requiring RNA services.
Medication Administration Error Due to Improper G-Tube Flushing
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as observed during a medication pass involving a Licensed Vocational Nurse (LVN) and a resident with a gastrostomy tube (G-Tube). The LVN did not flush the G-Tube with water between administering nine medications, resulting in a 33.3% medication error rate. This practice was contrary to the facility's policy, which requires flushing with at least 15 ml of water between medications to ensure safe administration. The resident involved had a history of metabolic encephalopathy and sepsis and was dependent on staff for daily living activities due to severely impaired cognitive skills. The LVN acknowledged the error during an interview, admitting that the lack of flushing could lead to drug reactions that might deactivate the medications. The Assistant Director of Nursing confirmed the correct procedure, emphasizing the importance of flushing to prevent medication errors.
Deficiency in RNA Services Due to Ineffective QAA System
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain an effective system to identify, monitor, and evaluate the implementation of a plan of correction for a previously cited deficiency. This deficiency, initially identified on 8/1/2024, was related to insufficient staffing of Restorative Nursing Assistants (RNAs) and Certified Nurse Assistants (CNAs) to provide necessary exercises and devices as ordered by physicians to prevent decline in residents' mobility. The deficiency affected 19 residents who were receiving RNA services, putting them at risk for further decline in range of motion, mobility, and contractures. During interviews, the Administrator and Director of Nursing (DON) were unaware of the continued issues related to RNA services, such as RNAs being reassigned to perform CNA tasks and residents not receiving RNA-assisted exercises and services as ordered. The DON admitted that the RNA services program was a collaboration between the Director of Staff Development (DSD) and the Director of Rehabilitation (DOR) services, but they were unaware of incorrect transcription of physician orders into the RNA record in the Electronic Medical Records (EMR) system. The facility's policies and procedures for Quality Assurance and Performance Improvement (QAPI) were reviewed, indicating a lack of effective tracking, measuring, and monitoring of performance, which contributed to the deficiency not being addressed in a timely manner.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection control policies and procedures, leading to several deficiencies involving five residents. For Resident 62, the suprapubic catheter drainage bag was found on the floor, which is against the facility's policy that requires catheter bags to be kept off the floor to prevent contamination. The Infection Control Nurse confirmed that the floor is dirty and could lead to contamination, potentially making the resident sick. For Residents 67 and 92, a Certified Nursing Assistant (CNA) did not perform hand hygiene before and after providing care to these residents. The CNA admitted to being too busy and forgetting to perform hand hygiene, which is crucial to prevent the spread of infection. The facility's policy mandates hand hygiene before and after direct contact with residents and handling food, which was not followed in this instance. Resident 78's feeding tubing was observed touching the floor, which poses an infection control risk. The Licensed Vocational Nurse acknowledged that the tubing should not be on the floor due to infection concerns. Additionally, Resident 77's family members were not following Enhanced Barrier Precautions (EBP) while in close contact with the resident, despite the resident being at high risk for infection. The family members were observed not wearing personal protective equipment (PPE) and handling dirty linens without gloves, increasing the risk of spreading multi-resistant drug organisms (MRDO).
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that two residents, Resident 16 and Resident 39, were offered the opportunity to formulate and receive information related to Advance Directives during their initial admission and subsequent re-admission. Resident 16, who has diagnoses including ventilator dependence, epilepsy, and a persistent vegetative state, did not have an advance directive noted in their Physician Orders for Life-Sustaining Treatment (POLST) form. The Social Services Director confirmed that Resident 16 had not been offered an advance directive since their first admission. Resident 39, diagnosed with ventilator dependence, muscular dystrophy, and quadriplegia, also did not have an advance directive on file. The Medical Records Director noted the absence of a signed Advance Healthcare Directive Acknowledgement (AHDA) form in Resident 39's medical record. Although the Social Services staff discussed advance directives with Resident 39, the AHDA form remained unsigned as Resident 39 wished to wait for a family member to sign on their behalf. The Social Services Director acknowledged that information regarding advance directives should have been provided to Resident 39 and their responsible party during the initial admission.
Failure to Transmit Discharge MDS Timely
Penalty
Summary
The facility failed to ensure the timely transmission of the Discharge Minimum Data Set (MDS) to the Centers for Medicare and Medicaid Services (CMS) for one resident, identified as Resident 87. This deficiency was identified during a review of Resident 87's records, which showed that the resident was originally admitted on January 30, 2024, and readmitted on July 14, 2024, with diagnoses including metabolic encephalopathy, heart failure, diabetes mellitus, and hyperlipidemia. The resident was discharged to an Assisted Living Facility on August 30, 2024, but the discharge MDS was not completed or transmitted within the required 30-day period. During an interview, the Minimum Data Set Nurse (MDSN) admitted to forgetting to complete the discharge MDS for Resident 87. The Director of Nursing (DON) emphasized the importance of completing and submitting all MDS assessments on time to ensure accurate reporting to CMS. The facility's failure to complete and transmit the discharge MDS in a timely manner had the potential to affect the quality-of-care monitoring system, which is crucial for ensuring safe and efficient resident-centered care.
Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
The facility failed to adhere to professional standards of practice in nursing care for Resident 86 by not checking for gastric residual volume before administering medications via a Gastrostomy Tube (G-Tube) and not flushing the G-Tube with water between each medication. During a medication pass observation, a Licensed Vocational Nurse (LVN) was seen administering medications to Resident 86 without checking for residuals and without flushing the G-Tube with water between medications. This practice was contrary to the facility's policy, which requires flushing with at least 15 mL of water before and between medications, and checking for residuals to ensure proper digestion and reduce the risk of complications. Resident 86, who was admitted to the facility with diagnoses including metabolic encephalopathy and sepsis, had severely impaired cognitive skills and was dependent on staff for daily living activities. The facility's policy on administering medications through an enteral tube emphasizes the importance of verifying tube placement and flushing with water to prevent complications such as aspiration and clogged tubes. The Assistant Director of Nursing (ADON) confirmed the necessity of these procedures, highlighting the potential for drug interactions and the importance of proper medication administration techniques.
Failure to Implement Bowel and Bladder Training Leads to Resident Fall
Penalty
Summary
The facility failed to initiate routine bowel and bladder training programs for a resident, identified as Resident 198, who was assessed as being at high risk for falls. Resident 198, who was admitted with diagnoses including spinal stenosis and lack of coordination, required partial assistance for activities of daily living, including toileting. Despite being identified as high risk for falls due to factors such as intermittent confusion, poor safety awareness, and a history of falls, the facility did not implement a bowel and bladder toileting program for the resident. On the day of the incident, Resident 198 was observed walking out of his room and falling over a plastic wet floor sign placed in front of his room. The resident was attempting to use the restroom unassisted, which led to the fall. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that Resident 198 was not on a bowel and bladder training program, despite having episodes of continence and incontinence and being able to make his needs known. The staff acknowledged that such a program should have been initiated after the resident's second fall in the facility. The facility's policy and procedure for behavioral programs and toileting plans for incontinence, which includes bladder rehabilitation and toileting plans, was not followed for Resident 198. The failure to implement these programs contributed to the resident's fall, as the resident attempted to find a restroom without assistance. The incident highlights the facility's oversight in addressing the resident's toileting needs and ensuring a safe environment to prevent falls.
Inadequate Supervision and Hazardous Environment Lead to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures to prevent a fall for a resident identified as high risk for falls. The resident, who had a history of falls and was diagnosed with spinal stenosis and lack of coordination, was observed falling over a plastic Wet Floor sign placed in front of his room. The resident's care plan indicated a need for frequent supervision and monitoring due to his unsteady gait and balance issues. However, during the incident, the Licensed Vocational Nurse (LVN) responsible for monitoring was on the other side of the station, preparing to pass medication, and was not present to prevent the fall. The housekeeper had placed the Wet Floor sign in front of the resident's door after mopping, intending to alert others of the wet floor. However, this action inadvertently created a hazard for the resident, who was known to have poor safety awareness and an unsteady gait. The Director of Nursing acknowledged that the environment should be free of clutter and hazards, especially for high fall-risk residents, and that the placement of the Wet Floor sign was inappropriate in this context. The facility's policy emphasized the importance of maintaining a safe environment and providing supervision to prevent accidents, which was not adhered to in this instance.
Inadequate Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate assessments, treatments, and services for a resident who was incontinent of bladder and had an indwelling Foley catheter for wound care management. The resident's Foley catheter was not properly secured to her leg, which could lead to dislodgement and potential trauma. Additionally, sediment was observed in the urine, indicating a possible urinary tract infection (UTI), but there was no documentation of the urine's color and consistency for a month. The resident was admitted with diagnoses including respiratory failure, a stage 4 pressure ulcer, and sepsis. The care plan included monitoring for signs of UTI and maintaining proper catheter alignment. However, during observations, the catheter was found unstrapped and with sediment, and there was no evidence of catheter flushing as ordered. Interviews with staff revealed that the licensed nurses were responsible for assessing the urine characteristics and ensuring the catheter was properly secured, but these actions were not consistently documented or performed. The facility's policy required immediate reporting of unusual findings to a physician, but there was no documented change of condition evaluation for the sediment in the catheter. The Assistant Director of Nursing confirmed that sediment in the catheter was not normal and should have been reported to the physician. The facility's failure to adhere to its policies and procedures for catheter care and change in condition reporting contributed to the deficiency.
Failure to Use Alternatives Before Side Rails
Penalty
Summary
The facility failed to use appropriate alternative interventions before installing bilateral upper half side rails for a resident, identified as Resident 298. The resident was admitted with acute respiratory failure, hemiplegia, hemiparesis, and was receiving surgical aftercare. The facility's documentation indicated that side rails were used due to the resident sliding down in bed, related to an elevated head of bed for tube feeding. However, there was no documented evidence of alternative interventions being attempted prior to the use of side rails. The informed consent document for the use of side rails was incomplete, lacking a physician's signature and only indicating verbal consent from the resident, who was noted to lack the capacity to understand and make decisions. The facility's assessment and care plan documents also failed to show any attempts at alternative measures before resorting to side rails. Observations confirmed the use of side rails, and interviews with staff revealed a practice of automatically placing residents on side rails upon admission, without documented evidence of alternative interventions. The facility's policy required attempts to use alternatives before side rails, but this was not followed. Interviews with staff, including a CNA, LVN, and RN, indicated a lack of documentation and monitoring for side rail use, and the ADON confirmed that alternatives were not attempted. The facility's failure to adhere to its own policies and procedures regarding bed safety and side rail use resulted in a deficiency, as it did not ensure the safety and proper assessment of the resident's needs before implementing side rails.
Failure to Complete Annual Competency Assessments for Staff
Penalty
Summary
The facility failed to ensure that one Licensed Vocational Nurse (LVN 2) and one Certified Nursing Assistant (CNA 3) completed their annual competency assessments and evaluations. LVN 2 was hired on April 3, 2020, and their competency checklist was dated November 17, 2023, indicating a lapse in the annual assessment for the previous year. Similarly, CNA 3, hired on January 28, 2005, had a competency checklist dated December 3, 2023, also showing a failure to complete the annual assessment in 2024. During interviews, the Director of Nursing (DON) acknowledged that all licensed nurses should complete competency skills upon hire and annually, but was unaware of why LVN 2's assessment was not completed the previous year. The Director of Staff Development (DSD) confirmed that competency evaluations are conducted via written tests and return demonstrations upon hiring and annually for all staff, but could not explain why CNA 3's assessment was not completed in 2024. The facility's policy, revised in August 2022, states that the facility provides sufficient numbers with the appropriate skills and competency necessary to provide nursing-related care and services for all residents.
Failure to Conduct Required Joint Mobility Assessments
Penalty
Summary
The facility failed to provide required specialized rehabilitation services for a resident, specifically in the area of joint mobility assessments. Resident 14, who has diagnoses including hemiplegia and diabetes mellitus, was not assessed for potential joint mobility concerns annually and quarterly as required. The last documented occupational therapy (OT) joint mobility screening for the resident was completed in 2022, and no subsequent screenings were found in the resident's medical record for 2024. This oversight was acknowledged by the Director of Rehab, who confirmed that the annual physical therapy (PT) joint mobility assessment for 2024 was missed, and the last OT assessment was completed in 2022. The Director of Nursing emphasized the importance of joint mobility assessments in preventing contractures and maintaining residents' functional independence. The facility's policy requires joint mobility assessments to be conducted upon admission, readmission, and annually, in conjunction with the Minimum Data Set (MDS) assessment schedule. The failure to conduct these assessments as per policy was identified during a review of the facility's policy and procedure, which mandates that joint mobility screenings be completed by PT and/or OT. This deficiency had the potential to negatively impact the resident's physical and mobility function.
Failure to Explain Arbitration Agreement to Resident's Responsible Party
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to the responsible party of a resident, identified as Resident 198, who was admitted with diagnoses including dementia and cognitive communication deficit. The responsible party, listed as Family Member 1, reported not understanding the arbitration agreement or the rights to make informed decisions about the resident's care. Despite signing the arbitration documents, Family Member 1 stated that the forms were handed over without explanation, and she was not informed about the meaning of the arbitration agreement. The Admissions Coordinator indicated that the arbitration information document was self-explanatory and that the responsible party could read it themselves, but was not allowed to answer any questions. The Administrator acknowledged that the arbitration agreement should have been explained in a manner that the responsible party could understand, as per the State Operations Manual Appendix PP. The failure to ensure comprehension of the arbitration agreement resulted in the responsible party being unable to make an informed decision regarding the resident's care.
Non-Operational Call Light System for Multiple Residents
Penalty
Summary
The facility failed to maintain a functioning call light system for three residents, which was identified during an observation and interview process. Resident 5, who has chronic obstructive pulmonary disease and Alzheimer's disease, was unable to alert staff for assistance due to a non-operational call light. Despite having the call light in hand and pressing it repeatedly, the system did not signal at the nurse's station or outside the room. Similarly, Residents 48 and 62, both with conditions affecting mobility and communication, were also found to have non-functioning call lights, preventing them from effectively requesting assistance. The issue was confirmed during an interview with the Assistant Director of Nursing and the Infection Preventionist Nurse, who verified that the call lights for all three residents were not functioning properly. The Maintenance Supervisor later stated that the malfunction had not been reported to the maintenance department, despite daily checks being conducted. The Director of Nursing emphasized the importance of operational call lights for resident safety and timely care, as outlined in the facility's maintenance policy.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that resident bedrooms met the required minimum size of 80 square feet per resident in multiple resident rooms. Specifically, 11 out of 39 resident rooms were found to be below this standard, with rooms 5, 6, 8, 9, 11, 12, 14, 15, 16, 17, and 18 measuring less than the required square footage per resident. This deficiency was identified through observation, interviews, and record reviews, which revealed that the rooms did not meet the necessary space requirements for safe nursing care and resident privacy. Despite the deficiency, interviews with residents and staff indicated that the current room sizes did not adversely affect the residents' care or their ability to move freely. Residents reported that they could ambulate and transfer without issues, and staff confirmed that they could provide care by adjusting furniture to create necessary space. The facility's variance request suggested that the room sizes did not negatively impact residents' health, safety, or well-being.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to accommodate the needs of four residents by not responding to call lights in a timely manner. Resident 1, who was admitted with hemiplegia affecting both sides of the body and had moderately impaired cognition, reported that it took at least two hours for staff to respond to his call light. Resident 3, who was dependent on assistance for daily activities, also experienced delays of 1-2 hours during the night shift for diaper changes. Resident 4, with intact cognition but requiring moderate assistance, reported similar delays during the night shift. Resident 5, who required substantial assistance due to a fibula fracture, experienced delays of at least an hour for diaper changes, leading to feelings of neglect and discomfort. The Resident Council Meeting minutes indicated that residents had previously voiced concerns about the untimely response to call lights. The Director of Staff Development confirmed that call lights should be answered within five minutes, as per the facility's policy. However, the facility's failure to adhere to this policy resulted in increased risk for harm to the residents, as they were left waiting for assistance with personal hygiene and other needs.
Failure to Follow Influenza Vaccination Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure for influenza immunization for one of the residents. The resident, who was admitted with acute respiratory failure and cerebral aneurysm, was not properly offered the influenza vaccine. The facility did not provide the necessary education regarding the benefits and potential side effects of the vaccine, nor did it document the resident's refusal with the required name and signature on the Vaccine Consent Form. This oversight was identified during a review of the resident's records and interviews with the staff and the resident. The Licensed Vocational Nurse (LVN) claimed to have offered the influenza and Covid-19 vaccines to the resident, who allegedly refused them. However, the resident denied this, stating that the nurse did not present a Vaccine Consent Form or discuss the risks and benefits. The Director of Nursing (DON) confirmed that the facility's policy requires residents to sign a refusal form with two witnesses if they decline vaccination. The facility's policy also mandates that residents be informed and educated about the vaccine's benefits and side effects, which was not followed in this case.
Failure to Offer and Document Covid-19 Vaccine for Resident
Penalty
Summary
The facility failed to adhere to its Covid-19 policy and procedure for a resident by not offering the Covid-19 2024/2025 vaccine, not providing education about the vaccine's benefits and risks, and not properly documenting the resident's refusal. The resident, who was admitted with acute respiratory failure and a cerebral aneurysm, had moderately impaired cognition and required substantial assistance with daily activities. Despite a Vaccine Consent Form indicating refusal, it lacked the resident's name and signature, and the resident later tested positive for Covid-19. Interviews revealed discrepancies in the facility's handling of the vaccine offer. A Licensed Vocational Nurse claimed to have offered the vaccine, which the resident allegedly refused, but the resident denied this, stating they were not shown a consent form or informed about the vaccine's risks and benefits. The Director of Nursing confirmed the facility's policy of offering vaccines and requiring a signed refusal form with witnesses if declined. However, the facility's failure to document the refusal properly and provide education as per policy led to the deficiency.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its policies and procedures regarding the prevention of abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified when a resident expressed discomfort with a male Certified Nursing Assistant (CNA) providing pericare, yet the facility did not investigate or report the incident as required by federal regulations. The resident had informed a Registered Nurse (RN) that she did not want the male CNA to provide care, but the CNA was assigned to her again the following day, which made the resident feel unsafe. The resident, who was admitted with diagnoses including acute chronic respiratory failure and severe cognitive impairment, was dependent on facility staff for personal care. Despite the resident's clear preference for female CNAs, the facility's staffing assignments did not reflect this preference, leading to the same male CNA being assigned to her care again. The Assistant Director of Nursing (ADON) was only informed of the resident's preference after the CNA had been reassigned, indicating a breakdown in communication and adherence to the facility's abuse prevention policies. Interviews with facility staff revealed that the RN who was initially informed of the resident's discomfort did not report the incident to the Director of Nursing (DON) or the Administrator, who is the abuse coordinator. Additionally, the Director of Staff Development (DSD) was unaware of the resident's preference when making staffing assignments. The facility's policies require immediate reporting and investigation of any allegations of abuse, but these procedures were not followed, resulting in the resident's continued distress and the facility's failure to protect her from potential abuse.
Failure to Document Resident's Belongings Leads to Loss
Penalty
Summary
The facility failed to document a resident's belongings, specifically a rosary, leading to its loss. The resident, who had severe cognitive impairment and was dependent on facility staff for personal care, was admitted and readmitted with various diagnoses, including anoxic brain damage. During the resident's stay, a family member reported that the rosary, given by a priest, was missing after the resident was transferred to a different care unit. The facility's inventory list did not include the rosary, although it was acknowledged by a CNA that the resident had it along with other personal items. Interviews with facility staff, including a CNA, LVN, DON, and SSD, revealed that the facility's policy required new items to be documented on the inventory list, but this was not done for the rosary. The DON stated that items from church services were not typically documented, which contributed to the oversight. The facility's grievance report confirmed the missing items and noted attempts to contact the family for descriptions to replace them. The facility's policy emphasized the importance of documenting personal belongings upon admission and updating the inventory as necessary.
Failure to Follow Up on Dental X-ray Recommendation
Penalty
Summary
The facility failed to provide medically related social services for a resident by not following up on a dentist's recommendation for an x-ray to evaluate an aching tooth. The resident, who was admitted and readmitted to the facility with diagnoses including anoxic brain damage and severe cognitive impairment, was dependent on staff for personal care. The dentist recommended an x-ray to confirm the source of the resident's pain, but the x-ray was not performed as of the review date. Interviews with facility staff revealed a breakdown in communication and responsibility. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) both stated they were unaware of the dentist's recommendation for an x-ray. The Social Services Director (SSD) acknowledged that it was their responsibility to follow up on dental recommendations, but the recommendation for the x-ray was missed. The facility's policy indicated that social services staff were responsible for obtaining needed services, but this was not executed, potentially leading to the resident experiencing pain and further dental issues.
Deficient Infection Control Practices in Linen Handling
Penalty
Summary
The facility failed to adhere to its infection prevention and control practices, specifically in the handling and storage of dirty linen, which affected six residents. The deficiency was identified during a survey where it was found that dirty linens, including those from isolation rooms, were not being managed according to the facility's policy. Certified Nursing Assistant (CNA) 1 reported that isolation linens were placed in single black bags without being double-bagged or labeled, which could lead to cross-contamination and the spread of infection. Interviews with the Laundry Personnel (LP) revealed that isolation linens were supposed to be double-bagged and labeled with the resident's room and bed number to distinguish them from regular dirty linens. However, the LP noted that both types of linens were placed in black bags, and without proper labeling or double-bagging, it was challenging to identify isolation linens, increasing the risk of infection spread. The Director of Nursing (DON) stated that all linens were considered dirty and that the washing process should eliminate microorganisms, but this did not align with the facility's policy for handling isolation linens. The facility's policies on standard precautions, laundry handling, and infection control emphasized the need for proper handling and processing of soiled linens to prevent contamination and the spread of infections. Despite these policies, the facility's practices did not ensure that isolation linens were managed in a manner that prevented the transfer of microorganisms, as required by their infection control program. This oversight had the potential to increase the spread of infections within the facility.
Failure to Notify Physician After Resident Fall
Penalty
Summary
The facility failed to notify the physician after a resident fell from a shower chair on August 1, 2024. This incident involved a resident who was admitted to the facility on January 25, 2019, and readmitted on August 9, 2024, with diagnoses including muscle weakness, osteoarthritis of the left ankle and foot, and unspecified dementia. The resident was moderately impaired cognitively and required supervision during showering. Despite the fall, there was no documented evidence in the resident's electronic medical chart indicating that the physician or the responsible party was notified of the incident. During an interview, the Assistant Director of Nursing (ADON) stated that he was unaware of the fall until August 15, 2024, and confirmed that there was no documented evidence of a Change of Condition assessment, SBAR Communication Form, skin assessment, 72-hour neurological checks, or an interdisciplinary team meeting conducted after the fall. The facility's policy and procedure require prompt notification of the resident's attending physician and representative in the event of an accident or incident, which was not followed in this case.
Failure to Update Care Plans for Residents with Falls and Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. For the first resident, who had a history of falls and was at risk due to muscle weakness, osteoarthritis, and dementia, the facility did not document a fall that occurred on 8/1/2024. Despite the resident's care plan indicating a risk for falls and requiring frequent supervision, the plan was not updated after the fall incident. The Assistant Director of Nursing acknowledged that the care plan was not revised to address the fall and prevent future incidents. The second resident, who had acute respiratory failure, cerebral palsy, and Type 2 Diabetes Mellitus, was involved in a grievance related to disruptive behavior in their shared room. The facility's records showed a grievance about the resident's behavior of playing with privacy curtains and having the television volume too loud, which disturbed another resident. Although the facility recommended that nursing supervisors conduct rounds to monitor safety and noise levels, these recommendations were not documented in the resident's care plan. Nursing staff were unaware of the need to monitor the behavior and noise levels, as the care plan was not updated to reflect these concerns. The facility's policy on care plans requires ongoing assessments and updates when there are significant changes in a resident's condition. However, in both cases, the care plans were not revised to address the incidents and recommendations, leading to potential risks for the residents involved. The lack of documentation and communication among staff contributed to the deficiencies in care planning and implementation.
Inadequate Pressure Ulcer Care Due to Insufficient Supplies
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for two residents. Resident 1, who was admitted with a stage 4 pressure ulcer in the sacral region, had a care plan that included specific interventions such as administering treatment as ordered and monitoring for signs of infection. However, during incontinent care, the facility did not follow its policies and procedures, which included using appropriate materials to clean the resident. Instead, a reusable washcloth was used, which was rough and could potentially cause skin irritation or tears. Resident 2, who had a stage 3 pressure ulcer, also experienced inadequate care. The care plan for this resident included similar interventions to minimize the risk of complications and promote healing. However, during an observation, a CNA used a reusable washcloth to clean the resident after a bowel movement, which was against the facility's policy. The CNA was unaware of where to find disposable cleansing wipes, which were supposed to be used to prevent skin irritation and promote healing. The facility's supply of disposable wipes was insufficient, as noted during an interview with the Central Supply staff. The facility had recently used a significant portion of its supply due to a water shut-off, and there were concerns about not having enough wipes if the water was shut off again. This lack of supplies contributed to the use of inappropriate cleaning materials, which could hinder wound healing and cause discomfort to the residents.
Failure to Investigate and Address Fall Risk
Penalty
Summary
The facility failed to investigate and implement interventions for a resident with a history of falls, who experienced a recurrent fall on 8/1/2024. The resident, who was admitted with diagnoses including muscle weakness, osteoarthritis, and unspecified dementia, was found to have fallen after attempting to stand from a shower chair without shoes. The resident's Minimum Data Set indicated a need for supervision during certain activities, yet the fall was not documented or investigated, and no interventions were implemented to address the resident's fall risk factors. The incident occurred when a CNA left the resident unattended in a shower chair while moving a wheelchair that was blocking the path to the resident's bed. The CNA heard a noise and found the resident on the floor, having slipped and hit her head. Despite the incident, there was no documentation in the resident's electronic medical chart, and the Assistant Director of Nursing was unaware of the fall until two weeks later. The facility's fall protocol, which includes incident reporting, physician and family notification, and post-fall assessments, was not followed. The facility's policies require thorough documentation and investigation of falls, including assessments of vital signs, neurological status, and pain, as well as an evaluation of precipitating factors. However, these procedures were not adhered to in this case, as there was no evidence of a Change of Condition assessment, SBAR communication, care plan update, or interdisciplinary team meeting following the fall. This lack of action and documentation represents a significant deficiency in the facility's care and supervision of the resident.
Deficiency in Restorative Nursing Assistant Services
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents requiring Restorative Nursing Assistant (RNA) services. Specifically, the RNA, who is a certified nursing assistant with specialized training in rehabilitation skills, was assigned to perform regular CNA duties instead of focusing on RNA-specific tasks such as range of motion exercises. This affected 19 residents on the RNA program, including a resident with a physician's order for RNA-assisted exercises, who reported not receiving these services for the past two months. The resident's medical history includes muscle weakness, functional quadriplegia, and an acquired absence of the left leg below the knee, necessitating regular RNA exercises to maintain mobility and prevent joint stiffness. Interviews with staff revealed that when no RNA was scheduled, CNAs attempted to provide RNA exercises during their regular duties, but this was inconsistent and not in line with specific physician orders. The Director of Staff Development and the Director of Rehabilitation had differing views on whether ADL activities could substitute for RNA exercises, with the latter emphasizing the need for dedicated RNA services. The facility's policy stated that restorative nursing care should be individualized and resident-centered, but the lack of a clear list of residents in the RNA program and the absence of scheduled RNAs led to a failure in delivering these essential services.
Failure to Update and Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was updated and posted in a visible and prominent place, as required. On July 31, 2024, it was observed that the staffing information posted in front of the Subacute Nursing Station was outdated, displaying information from July 25, 2024. This was verified with a Registered Nurse (RN) who explained that the posting was not updated in the morning due to a last-minute change in RN staffing assignments. An RN called off for the Skilled Nursing Facility (SNF) Station, necessitating a reassignment of staff, which delayed the update of the staffing information. According to the facility's policy, direct care daily staffing numbers should be posted for every shift, but this was not adhered to, resulting in the deficiency.
Inaccurate Documentation of Care by RNA
Penalty
Summary
The facility failed to maintain accurate clinical records in accordance with professional standards for a resident, identified as Resident 6. The Restorative Nurse Assistant (RNA) 1 admitted to documenting that she provided range of motion exercises to Resident 6 on specific dates, even though she was not present at the facility on those days. This inaccurate documentation was done at the request of CNA 4, who claimed to have completed the tasks but asked RNA 1 to document them. The facility's records, including staffing assignments and punch details, confirmed that RNA 1 was not on duty on the dates in question. Resident 6, who had a history of diabetes mellitus and a below-knee amputation, required substantial assistance with daily activities and was ordered by a physician to receive RNA-assisted exercises. The facility's policy stated that documentation should include the name and title of the individual providing care, which was not adhered to in this case. Interviews with the Director of Staff Development and the Director of Nursing confirmed that the practice of documenting care not personally provided was against the facility's standards and policies.
Failure to Notify Physician and Family of Self-Decannulation
Penalty
Summary
The facility failed to notify the physician and family of a resident who self-decannulated their tracheostomy tube multiple times. The resident, who had a history of self-decannulation, was readmitted to the facility with several diagnoses, including cerebral infarction, aphasia, and respiratory failure. The resident's care plan included interventions for tracheostomy tube care and required notification of the physician and family in case of decannulation. However, the facility did not document or notify the physician or family when the resident self-decannulated on one occasion. The resident's physician orders included monitoring for anxiety and the use of a freedom splint to prevent pulling out life-sustaining tubes. Despite these measures, the resident managed to remove the tracheostomy tube on multiple occasions. On one specific incident, the resident removed the tube at 3:30 AM, and although the respiratory therapist successfully reinserted it, there was no documented evidence of a change of condition or notification to the physician or family. Interviews with the Director of Nursing and a Licensed Vocational Nurse confirmed the lack of documentation and notification. The facility's policy required prompt notification of changes in a resident's condition to the physician and family, but this was not followed. The failure to notify the physician and family of the resident's self-decannulation was identified as a deficiency in the facility's care practices.
Failure to Update Care Plan for Resident with Tracheostomy
Penalty
Summary
The facility failed to implement a care plan consistent with professional standards of practice for a resident with a tracheostomy, who had a history of self-decannulation. The resident, who had moderately impaired cognition and lacked the capacity to make decisions, had self-decannulated three times while at the facility. Despite the resident's history and the physician's orders to monitor anxiety and use interventions like Ativan and a freedom splint, the care plan was not updated to address the self-decannulation incidents. The resident's care plan, initiated on 6/7/2024, acknowledged the risk of accidental decannulation but only included notifying the physician and responsible party if decannulation occurred. The facility's Director of Nursing (DON) acknowledged that there was no documented evidence of an updated care plan following the self-decannulation incidents on 6/9/2024 and twice on 6/23/2024. The DON emphasized the importance of updating the care plan to prevent further incidents, indicating that the existing interventions were insufficient. The facility's policy and procedure for comprehensive, person-centered care plans require measurable objectives and timetables to meet residents' needs. However, the care plan for this resident did not reflect the necessary updates or interventions to address the repeated self-decannulation events. The facility's failure to update the care plan as required by their policy and procedure contributed to the deficiency identified in the report.
Failure to Ensure Use of Abdominal Binder for G-tube Resident
Penalty
Summary
The facility failed to provide necessary care and services to a resident with a Gastrostomy tube (G-tube) by not ensuring the use of an abdominal binder as ordered by the physician. During an observation, it was noted that the resident's G-tube was not anchored, and the abdominal binder was not in use. The Licensed Vocational Nurse (LVN) explained that the resident's abdominal binder was sent to the laundry because it was soiled, and there was no spare binder available for use during this time. The resident, who was admitted with multiple diagnoses including cardiac arrest, anoxic brain damage, respiratory failure, and tracheostomy status, was severely impaired cognitively and required extensive assistance for daily activities. The resident's care plan and physician orders specifically indicated the use of an abdominal binder to prevent G-tube dislodgement. However, the absence of the binder due to laundry needs and lack of a replacement posed a risk of G-tube dislodgement, which could lead to complications.
Failure to Document Rationale for PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the prescribing physician documented the rationale for extending the use of two PRN psychotropic medications for two residents, as required by the facility's policy and procedure on psychotropic medication use. This deficiency was identified through observation, interview, and record review. The facility's policy mandates that psychotropic medications are not prescribed or given on a PRN basis unless necessary to treat a diagnosed specific condition documented in the clinical record. Furthermore, if the prescriber believes it is appropriate to extend the PRN order beyond 14 days, they must document the rationale for extending the use and include the duration for the PRN order. Resident 1 was admitted with diagnoses including unspecified psychosis and anxiety disorder and was dependent on assistance for daily activities. The physician ordered Valium 2 mg to be administered via G-tube every 4 hours as needed for anxiety, with the order set for 14 days. However, there was no documented evidence from the attending physician providing a reason or rationale for reordering and continuing the Valium every 14 days. The Director of Nursing (DON) confirmed the absence of such documentation during a record review. Resident 2, who was readmitted with diagnoses of unspecified major depressive disorder and anxiety disorder, required substantial assistance with daily activities. The physician ordered Lorazepam 0.5 mg to be given via G-tube every 12 hours as needed for anxiety, also for 14 days. Similar to Resident 1, there was no documented rationale from the attending physician for reordering and continuing the Lorazepam every 14 days. The DON acknowledged that the facility nurses were reordering the psychotropic PRN medications without documentation from the prescribing physicians, which was against the facility's policy that requires residents to be evaluated by their attending physician before renewing PRN psychotropic medications.
Failure to Investigate and Resolve Grievance Regarding Missing Specialized Wheelchair
Penalty
Summary
The facility failed to review and investigate the allegations made by a resident's representative (RP 1) regarding a missing specialized wheelchair for Resident 1. Despite RP 1's complaint, the facility did not make prompt efforts to resolve the problem or provide a written response to RP 1. The facility's inaction was contrary to its policies and procedures, which require prompt resolution and written communication of grievances. Resident 1, who had chronic respiratory failure and quadriplegia, was dependent on others for daily living activities and had no discernible consciousness according to the Minimum Data Set (MDS) dated 3/21/24. RP 1 reported that Resident 1's specialized wheelchair was missing and that the facility had thrown it away without informing RP 1. During an interview, a Certified Nurse Assistant (CNA 1) confirmed that the wheelchair was deemed unsafe and was no longer in use, but she did not know its current location. The Assistant Director of Nursing (ADON) acknowledged that RP 1 had raised the issue during an Interdisciplinary Meeting (IDT) on 2/20/24, but the grievance was not documented or addressed. The Maintenance Director also confirmed that the previous administrator had disposed of the wheelchair. The Social Services Director (SSD) stated that she filled out a Grievance Report on 3/26/24 after being informed by RP 1 about the missing wheelchair. Her investigation revealed that the wheelchair was discarded due to its poor condition. However, there was no prior grievance record on file before March 2024. The facility's policy requires that any grievance be reviewed, investigated, and a written report submitted to the administrator within five working days, which was not followed in this case.
Failure to Update and Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to update and revise the care plan for two residents, leading to deficiencies in their care. For Resident 1, the care plan was not updated after the resident tested positive for Carbapenem-resistant Acinetobacter baumannii (CRAB) and required isolation. Despite the physician's order for isolation, the care plan continued to include out-of-room activities without reflecting the isolation requirement. This oversight occurred even though the resident had been diagnosed with chronic respiratory failure and quadriplegia and was dependent on others for all activities of daily living. The care plan had not been updated since the isolation order was given, failing to provide the necessary information for staff to follow the isolation protocol effectively. For Resident 3, the care plan was not revised to include the resident's specific music preferences, despite the facility identifying that the resident enjoyed listening to the Black Eyed Peas. The care plan only mentioned general activities of interest such as music, outdoor activities, exercise, reading, and television, without specifying the resident's preference for the Black Eyed Peas. This omission occurred even though the resident had severe cognitive impairment and was dependent on others for all activities of daily living. Interviews with the Activity Director, MDS Coordinator, and Director of Nursing confirmed that care plans should be person-centered and updated to reflect changes in the resident's condition or preferences, which was not done in these cases.
Latest citations in California
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
