Valencia Hills Health And Rehabilitation Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent resident-to-resident altercations and inappropriate contact on a secured dementia unit. On one unit, surveyors observed two residents yelling at each other in the dining room while an activities aide sat at the table and a nurse and medical records coordinator did not intervene for approximately two minutes. During this time, another resident with severe cognitive impairment and anxiety walked unimpeded across the dining room, poked and shoved the head of a resident seated in a wheelchair, then moved to another resident seated on the far side of the room and, after unintelligible verbalizations and the other resident yelling “go back,” slapped that resident on the arm. Staff only began to approach after these interactions had already escalated. Multiple staff interviews acknowledged that residents on this unit wander, become more aggressive after sundown, and that there is not enough supervision. Record review showed that the resident who initiated the physical contact had diagnoses including unspecified dementia, major depressive disorder, brief psychotic disorder, and severe cognitive impairment (BIMS 00), and was on a secured unit with care plan interventions to cue, orient, and supervise as needed. The resident had a documented history of being the aggressor in a prior resident-to-resident altercation and was considered unstable enough to require psychiatric assessment. The resident who was slapped had diagnoses of unspecified dementia and vascular dementia with agitation, moderate cognitive impairment (BIMS 11), and was also on the secured unit with a care plan indicating the need for assistance with all decision making and supervision as needed. Staff, including CNAs, an RN, and the interim DON, reported that residents wander into each other’s rooms frequently, that activities are insufficient to keep all residents engaged, that staffing is sometimes short, and that there was not enough supervision on the unit. A separate deficiency event involved a resident with severe cognitive impairment and elopement risk who wandered the halls and into other residents’ rooms, and another resident with dementia and documented sexually inappropriate behaviors. Observations showed the cognitively impaired resident wandering near a hall door, attempting to enter a room that was not theirs, and continuing to wander and talk with other residents. The wandering resident’s care plan identified them as an elopement risk/wanderer with interventions such as distraction with structured activities and other diversions. The other resident had diagnoses including Alzheimer’s disease, unspecified dementia, and major depressive disorder, with an MDS indicating severe cognitive impairment and frequent wandering, and a care plan noting that the resident could be sexually inappropriate and should be redirected and provided alternative activities. Interviews with the wandering resident’s family member revealed that another resident repeatedly sought out this resident, attempted to call them into their room, and was later found groping the resident’s breast in that room. Staff, including CNAs and the unit manager LPN, confirmed that the sexually inappropriate resident had previously touched another resident in a similar manner, that the facility was aware of this resident’s sexual behaviors and habit of touching themselves, and that residents routinely wander into each other’s rooms. Staff statements reflected uncertainty about how often residents were checked when not in the dining room, a belief by some that residents entering each other’s rooms was not dangerous, and acknowledgment by others that wandering is dangerous because staff do not know what is happening behind closed doors. The NHA stated that despite a prior similar incident, the sexually inappropriate resident was not viewed as an aggressor and that, although the resident was removed from 1:1 at one point, the facility still should have been monitoring this resident more often than usual rounds. The facility’s abuse and neglect policy defined abuse, neglect, and sexual abuse, and required prevention of abuse and neglect and elimination of ongoing danger to residents, but staff interviews and observed events showed that residents with known behavioral and sexual issues were not consistently supervised to prevent further resident-to-resident contact and altercations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to operate a low-temperature dishwashing machine in accordance with professional food service safety standards and its own policy. During a kitchen tour with the Certified Dietary Manager (CDM) and Regional Dietary Manager, the CDM explained that the dish machine was designed to wash at a minimum of 140°F and rinse at a minimum of 120°F, and to deliver a chlorine-based chemical sanitizer at 50–100 ppm, verified by litmus test strips that should turn medium to dark purple. Dietary staff reported they had been operating the dish machine that morning and had already run many crates of dishes through it. Observations showed staff spraying soiled dishes with a water hose, loading them into racks, and running them through the machine, with another staff member receiving the items on the clean side. When surveyors observed the dish machine in use, the wash and rinse temperatures met or exceeded the required levels, but repeated testing with litmus strips on wet, recently washed trays showed no color change, indicating no detectable chemical sanitizer was present on the dishes. Staff attempted to correct this by priming the sanitizer dispenser and running additional racks, but subsequent tests again showed no color change on the strips. During one full wash and rinse cycle, a crate of bowls and plates emerged from the machine with visible food debris still present; the soiled dishes were separated out, while the remaining plates were placed in the clean area. Because dishes were coming out still soiled, a valid chemical sanitizing test could not be demonstrated, and the observations confirmed that the dish machine was not sanitizing in accordance with the facility’s written dish machine use policy and specified parameters for chlorine concentration and temperature.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program, beginning with the cleanliness and maintenance of the laundry areas. Surveyors observed multiple laundry rooms and noted extensive gray dust/lint-like material on wire shelving, the bottoms of shelves, conduits, and the exteriors of washing machines. Debris such as wadded paper, bits of plastic, a dusty slipper, a black plastic comb, and wadded-up linens and blankets were found on the floors. An opened personal-sized bottle of purified water was stored among clean folded linens, and a bottle of air fragrance was stored on a folding table on top of a dusty towel. The Housekeeping Director stated the area was swept multiple times a day but acknowledged that staff did not wipe down the outside of washers and that certain items, such as the water bottle and air fragrance, should not be present in the clean area. Additional observations in the laundry area included ceiling repairs near an air duct with seams that appeared wet and joint tape hanging down, as well as flakes of white/cream-colored material on the floor under the air duct. Exhaust and wall fans in the laundry rooms were covered with gray fuzzy material and contained pieces of opaque plastic inside their cages. Blankets used to soak up water from a roof leak were left wadded on the floor next to a washer. In the sorting area, multiple large black plastic bags were stacked along a wall and on top of a linen cart, and a laundry aide did not know what was in them until opening one and finding pillows. When asked to demonstrate folding a blanket, the laundry aide dragged part of the blanket on the floor and held it against unprotected clothing while folding. The facility was unable to provide a policy specifically addressing cleanliness of the laundry room. The facility also failed to effectively manage its infection prevention and control program related to Clostridioides difficile (C. diff) surveillance, staff education, and documentation. The Interim DON/Infection Preventionist reported two confirmed C. diff cases and one resident currently being tested, but the April infection control log did not initially include one confirmed resident and one resident being tested. The IP stated that hand hygiene for C. diff should be performed with soap and water instead of alcohol-based hand rub but reported that no re-education on this had been started and also stated not knowing what constituted an outbreak. Clinical records showed residents with positive C. diff stool samples and antibiotic treatment with vancomycin, as well as another resident with diarrhea, physician orders for STAT labs and C. diff stool testing, and administration of anti-diarrheal medication, yet this resident’s testing status was not reflected on the infection control logs for the relevant halls. A further deficiency involved failure to provide pneumococcal immunization in accordance with facility policy. One resident’s vaccine consent form, signed by the legal representative, indicated consent for pneumococcal, RSV, and shingles vaccinations. The resident’s diagnoses included unspecified dementia without behavioral disturbance, moderate recurrent major depressive disorder, and brief psychotic disorder. Review of the resident’s January Medication Administration Record did not show that the consented vaccinations were ordered or administered, and progress notes did not document any refusal by the resident or rescission of consent by the representative. The Interim DON/IP stated the facility does not offer RSV or shingles vaccines and did not know why the resident did not receive the pneumococcal vaccine, despite the facility’s written policy requiring assessment of pneumococcal vaccination status upon or shortly after admission, offering the vaccine within 30 days when indicated, and documenting administration or refusal in the medical record.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure access to vision services for a resident with glaucoma who had intact cognition and used corrective lenses. The resident reported that she had requested to see an ophthalmologist months earlier and had been told she was placed on a list, but no follow-up occurred and she did not know why the request had not been addressed. Her admission record documented a diagnosis of glaucoma, and her quarterly MDS showed a BIMS score of 15/15 and use of corrective lenses. Her active care plan identified impaired visual function related to glaucoma, with interventions limited to observing, documenting, and reporting signs or symptoms of acute eye problems. Staff interviews revealed gaps in the process for arranging vision care. A CNA recalled that an eye doctor used to see residents but was unsure if that process was still in place and stated she would report any resident request for an eye doctor to the nurse, with the Unit Manager typically arranging appointments. An LPN confirmed that the resident had requested to see an ophthalmologist a couple of months earlier, but when the LPN attempted to document this in a logbook for vision care needs, the logbook could not be found. The LPN reported the request to the previous DON during a period when there was no Unit Manager. The interim DON described the facility’s process for vision exams, including notifying a nurse or supervisor, determining whether to use an in-house optometrist or an outpatient appointment, and having designated staff arrange appointments and transportation, but stated she was not aware of this resident’s request and acknowledged that the process did not achieve the expected outcome for the resident. The facility’s Resident Rights Policy states that residents have the right to communication with and access to services inside and outside the facility, which was not ensured in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the medication error rate was below 5%, with surveyors identifying 2 errors out of 27 observed medication administration opportunities, resulting in a 7.41% error rate. In one instance, an LPN administered multiple oral medications to a resident with cerebral atherosclerosis, vascular dementia, dementia, and hypertension, including donepezil 5 mg. The resident’s active orders, however, specified donepezil HCl 10 mg by mouth once daily for dementia, meaning the resident received only half of the prescribed dose. The LPN confirmed the tablets prior to administration, but the dose given did not match the active physician order. In a second instance, another LPN administered insulin lispro (Humalog KwikPen) to a resident with type 2 diabetes mellitus after obtaining a blood glucose level of 234 and dialing the pen to 3 units per the sliding scale order. The LPN stated she does not prime the insulin pen prior to administration and proceeded to inject the dose into the resident’s left lower abdomen, holding the dose knob for approximately 2 seconds. Manufacturer instructions for the Humalog KwikPen require priming before each injection to remove air and ensure correct dosing, and instruct holding the dose knob in place while counting to 5 seconds. The Interim DON acknowledged she had not provided staff education on insulin pen priming, could not properly demonstrate priming, and confirmed that priming is necessary to provide the correct insulin dose. Facility policy on administering medications requires verification of the right medication and right dosage before administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely diagnostic testing for a resident who developed new swelling in the right arm and hand. The resident, admitted with diagnoses including a right radius fracture, right ulna styloid fracture, chronic diastolic heart failure, and convulsions, had previously had a cast removed from the right arm. On the evening of 3/13/2026, nursing documentation noted swelling of the right arm and hand that felt hard and slightly warm to the touch, with range of motion within normal limits, and indicated that hospice and the facility physician were notified. In the early morning of 3/14/2026, a new order was placed for a venous ultrasound of the right upper extremity. On 3/15/2026 at 9:56 p.m., a nursing note documented that staff called the mobile radiology vendor about the ordered doppler, were told someone would come that day, but the vendor had not arrived to perform the test. The venous ultrasound was ultimately completed on 3/17/2026 at 11:01 a.m., revealing an occlusive radial deep venous thrombosis. The resident’s care plan identified risk for cardiac complications and included interventions to notify the physician of significant abnormalities and to observe, document, and report changes in color or warmth of extremities. Staff interviews indicated that CNAs were expected to report swelling to nurses immediately, and LPNs were expected to report changes in condition, including swelling, right away, with follow-up to outside vendors within the same shift if ordered radiology services did not occur. The DON stated that swelling in residents with chronic heart failure should be reported immediately, including on night shift, and that staff must call outside vendors again if they did not arrive to perform ordered procedures. Despite these expectations and position descriptions requiring LPNs and RNs to observe, report, and coordinate care with physicians and other health care team members, there was an unexplained delay between the identification of swelling, the ordering of the venous ultrasound, and the completion of the test.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide and document required 1:1 supervision, enhanced monitoring (EM), or continuous monitoring (CM) for multiple residents who had behavioral symptoms, suicidal ideation, or elopement risk. For one resident with dementia and behavioral disturbance who had pushed another resident, nursing notes documented placement on 1:1 monitoring after the altercation, but CNA assignment sheets for several subsequent shifts showed no resident listed or staff assigned for 1:1. On another date, a CNA was listed as assigned to 1:1 supervision without any resident name or room number, and on other shifts there was no 1:1 assignment at all, despite progress notes indicating the resident was on 1:1 or enhanced monitoring. A second resident with dementia, psychosis, and depression had an order for continuous observation for elopement. Progress notes described wandering, agitation, and increased supervision due to elopement risk. However, CNA assignment sheets for multiple shifts showed no resident documented or staff assigned for 1:1 supervision, and on one shift a CNA was assigned 1:1 supervision for two residents in the same room. A third resident with Alzheimer’s disease and documented suicidal ideation had physician orders for 1:1 supervision and continuous observation for suicide ideation. Progress notes repeatedly stated the resident remained on 1:1 or continuous observation, yet CNA assignment sheets showed staff assigned to 1:1 while also responsible for a full group of rooms, and on later dates there were no residents documented or staff assigned for 1:1 on any shift, even while notes continued to reference continuous observation. Another resident with depression and active suicidal thoughts had multiple physician orders for 1:1 observation and continuous observation for suicidal ideation following a behavioral incident. Progress notes documented a 24‑hour sitter, ongoing 1:1, and continued close observation, but CNA assignment sheets for several dates and shifts showed no staff assigned for 1:1, including entire days with no 1:1 assignment despite notes indicating the resident continued on 1:1. A further resident with vascular dementia, agitation, and a history of wandering and resident‑to‑resident altercations was described in progress notes and psychiatric documentation as being on 1:1 supervision or enhanced monitoring after aggressive incidents, yet CNA assignment sheets and staffing records showed multiple shifts with no 1:1 assignment, shifts where EM was assigned to one CNA for two residents in different rooms, and night shifts with no EM or 1:1 documented for this resident. A final resident with dementia and sexually inappropriate behavior had a care plan intervention for enhanced monitoring after a sexual incident with a peer. Progress notes did not document 1:1, EM, or CM, and CNA assignment sheets showed shifts with no staff assigned for 1:1 or EM, as well as shifts where one staff member was assigned EM for this resident and another resident in different rooms. Interviews with nursing and CNA staff revealed inconsistent understanding and implementation of 1:1 and EM: one LPN stated staff should not have both a regular assignment and a 1:1 due to safety concerns, while CNAs reported being instructed to provide 1:1 while also caring for other residents, sometimes rotating the 1:1 among staff and bringing the supervised resident along while performing other care. Leadership interviews showed conflicting definitions of 1:1, EM, and continuous monitoring, disagreement about whether physician orders were required, and reliance on verbal reporting and care plans rather than consistent written assignments and documentation, despite multiple residents being described as on 1:1 or EM at the time.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to notify practitioners of abnormal laboratory results and to document such notifications as required by facility policy and resident care plans. For one resident with a primary diagnosis of a left ilium fracture and a care plan for hypothyroidism, a TSH level of 26.99 (reference range 0.45–5.33 uIU/mL) was reported by the lab on 3/7/26 at 5:55 p.m. The record later showed an order on 3/9/26 to increase Levothyroxine to 200 mcg daily and to repeat the lab in a week, and a nursing note that the resident’s son was informed of the medication increase and repeat lab. However, the documentation did not show that the practitioner was notified of the abnormal TSH result at the time it was reported, despite the care plan intervention to obtain and monitor labs and report results to the MD. Another resident with hypothyroidism had increased confusion documented, and the ARNP was notified with a request for labs. A urinalysis with microscopic exam was ordered and later reported with abnormal findings for urine blood, protein, mucus, and calcium oxalate crystals; the only documentation was that urine results were sent to the ARNP, without clear evidence of timely practitioner notification consistent with facility expectations. A third resident with idiopathic gout had multiple abnormal lab values (low RBC, Hgb, HCT; elevated Hemoglobin A1c and BUN) reported on 3/5/26, with a nursing note the next day stating results were sent to the physician. Subsequent labs on 3/7/26 again showed abnormal BUN and hematologic values, but the daily Medicare Managed Care note section for new labs was left blank, and there was no documentation that the physician was notified of these later abnormal results. Interviews with the DON, RN Unit Manager, and an LPN confirmed that staff are expected to notify practitioners of abnormal results as soon as possible and document this in the medical record, which was not consistently done for these residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement and document a comprehensive care plan intervention for enhanced or one-to-one supervision for a resident with known behavioral and cognitive impairments. The resident was admitted with multiple dementia-related diagnoses, including Alzheimer’s disease, vascular dementia with behavioral disturbances, anxiety disorders, and major depressive disorder. The facility’s reportable incident log documented a sexual allegation involving this resident and another resident. Following this, the resident’s comprehensive care plan identified that he could be sexually inappropriate at times related to his dementia diagnosis, and an intervention of “enhanced monitoring by staff as necessary” was added. However, review of progress notes from the days surrounding the incident showed no documentation of 1:1 supervision, enhanced monitoring, or continuous monitoring being provided. Interviews with facility staff revealed inconsistent understanding and implementation of supervision interventions. The DON stated that enhanced supervision was different from 1:1 supervision and that enhanced supervision did not require a physician order and was communicated verbally between nurses, with documentation expected in progress notes. In contrast, an RN/UM reported that 1:1 supervision and enhanced monitoring were the same and that an order would be in place for nurses to document, with the intervention reflected on the care plan and Kardex. The ADON stated that a physician order was needed for 1:1 supervision and that the expectation for residents on 1:1 or enhanced monitoring was implementation of a care plan and documentation in progress notes. Despite these expectations and the facility’s policy requiring care plans to be updated and implemented based on resident assessments and condition changes, there was no evidence in the record that the enhanced or 1:1 supervision interventions were consistently implemented or documented for this resident after the incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide and document incontinence and toileting care for a dependent, cognitively intact resident. The resident, admitted with multiple diagnoses including Type 2 diabetes mellitus, anemia, paroxysmal atrial fibrillation, legal blindness, gastrointestinal hemorrhage, and adjustment disorder with anxiety, reported many instances where they had a bowel movement and staff did not come in a timely manner to provide needed care. The resident’s Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and documented that the resident was always incontinent of bowel, used a wheelchair, had impaired lower extremity range of motion, and was dependent or required substantial/maximal assistance for toileting hygiene and toilet transfers. Record review of the resident’s bowel elimination task documentation revealed multiple shifts across January, February, and March where no care was marked, despite the resident’s total dependence on staff for toileting. Specifically, there were numerous 7 AM–3 PM, 3 PM–11 PM, and 11 PM–7 AM shifts with no documentation of bowel care provided. The resident’s care plan identified impaired physical mobility and self-care deficit, with interventions stating the resident was totally dependent on staff to meet toileting needs and would be toileted in bed with staff assistance, and also identified constipation related to opioid use, decreased mobility, and fear of pain, with interventions including encouraging the resident to sit on the toilet and following the facility bowel protocol. There were no physician orders specific to incontinence care and no progress notes documenting refusals of incontinence care during the review period. Interviews with nursing leadership and licensed staff confirmed that the facility’s expectation is that CNAs document toileting and incontinence care, including whether a resident voided, and that if care is not documented, it is considered not done. The RN/unit manager, an LPN, and the DON all stated there is no way to verify that toileting or incontinence care occurred if it was not charted. Position descriptions for RNs, LPNs, and CNAs require monitoring and documenting care, reporting changes in condition, and ensuring compliance with care plans and facility policies. The facility’s bowel and bladder/incontinence care policy requires that residents with any incontinence episodes be assisted with toileting or checked for incontinence at specified times (upon rising, before/after meals, activities, therapy, at bedtime, and as needed) and that CNAs document toileting as part of ADL care. Despite these policies and role expectations, the documentation gaps and the resident’s report of delayed care demonstrate that required incontinence and toileting care was not consistently provided or recorded for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure accurate and consistent documentation of controlled substances on shift-to-shift narcotic count sheets for multiple medication carts. Surveyors observed that the narcotic count sheet for cart 200-A had no entry for the current morning’s count, even though the assigned LPN stated the count itself was correct and that she had simply forgotten to record the total number of narcotic cards. During interviews, nursing staff described the facility’s process: at each shift change, the off‑going and oncoming nurses are required to count narcotic cards together, verify each resident’s narcotic medications, and both sign the Shift-to-Shift Controlled Medication Count. Staff also reported that discontinued or discharged narcotic cards remain in the locked narcotic box in the cart until the DON removes them with another nurse as witness. Further review of the narcotic binders for carts 100/A, 100/B, and 200/A revealed numerous discrepancies and incomplete or illegible entries. For cart 100/B, surveyors noted multiple instances where the total number of narcotic cards changed between shifts without any explanatory comments, as well as sequences of plus and minus entries that did not mathematically match the documented totals. Some entries showed beginning counts that did not align with the prior shift’s ending count, and there were illegible notations and unclear corrections. Similar issues were found in the 100/A narcotic ledger, including unexplained changes in total card counts, incorrect totals after documented additions and removals, missing shift counts, and entries written in the comments section instead of the total column. In several cases, the total number of cards increased or decreased without any corresponding explanation in the comment section. The 200/A narcotic count sheets also contained multiple inconsistencies. Surveyors identified shifts where the total narcotic card count decreased or increased from one shift to the next with no documentation in the comment section to explain the change, as well as a missing total entry for an entire shift. There were instances where a new count sheet was started without carrying over the prior total, resulting in a new starting count that did not match the previous ending count. Some entries contained illegible numbers and scratched-out totals before a final number was recorded. During interviews, the ADON and unit manager acknowledged that there were areas for improvement and inaccuracies in the ledgers, and one RN reported that when he left his cart keys with another nurse during a break, he did not document the narcotic count upon his return because the binder was in the ADON’s office. The facility’s own policies require that controlled substances be inventoried at each shift change by both incoming and outgoing nurses, that keys remain in the possession of a licensed nurse, and that all alleged misappropriation be reported, but the observed documentation practices and omissions did not consistently follow these requirements. Interviews with leadership and pharmacy personnel further clarified the existing processes and expectations but also underscored the documentation gaps. The ADON stated that when pharmacy delivers narcotics, the receiving nurse verifies the prescription with the delivery person, signs the delivery documentation, places the prescription in the narcotic book with a witness, and adjusts the shift-to-shift count. The ADON also stated that if a nurse relinquishes keys to another nurse for a break, the expectation is that narcotics are counted before and after the break, yet the RN who handed off his keys did not document a count upon return. Staff referenced at least one prior incident of a missing narcotic pill that was reportedly resolved, but the ADON indicated she had not had concerns about narcotic diversion during her tenure and believed pharmacy would alert the facility if there were issues. The consultant pharmacist reported that their role includes monthly medication review, checking for expiration dates, and verifying destruction of medications, but not checking narcotic counts beyond destruction processes. These combined observations and interviews demonstrate that the facility did not consistently maintain accurate, complete, and legible controlled substance count records as required by its own policies and regulatory expectations. The facility’s written policy on Schedule II controlled substances requires that when a controlled medication is administered, the nurse must document on the declining inventory sheet the date, quantity administered, amount remaining, and initials, and that an inventory count of all controlled medications on each unit be performed at each shift change by both incoming and outgoing nurses, with both signing the inventory form. The policy on abuse, neglect, exploitation, and misappropriation states that the facility will maintain an inventory of residents’ property and report alleged misappropriation in accordance with federal and state law. Despite these written requirements, the survey findings show repeated failures to document shift-to-shift narcotic counts accurately, to reconcile changes in total card counts, and to ensure that all required entries and signatures were present on the narcotic ledgers for multiple carts over an extended period.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure its Quality Assurance and Performance Improvement (QAPI) Committee effectively implemented and monitored corrective actions to prevent recurrence of previously identified problems with controlled medication documentation. The facility had been cited earlier under F755 for issues related to narcotic management and had developed a Plan of Correction with specific education and auditing processes. Education on narcotic shift-to-shift documentation, including requirements for count sheets, comment sections, signatures at the time of count, and counts when medications are received from the pharmacy, was initiated for nursing staff. Audit tools were also created with the stated goal of ensuring compliance with proper documentation on narcotic shift count sheets, and audit results showed 100% compliance on paper. Despite these measures, direct observations and record reviews showed that the corrective actions were not consistently carried out in practice. Review of Controlled Medication Inventory Sheets (CMIS) on multiple medication carts revealed incomplete and inaccurate documentation of narcotic counts over several days. On one cart, incomplete documentation of narcotic counts was found, and the RN present acknowledged that someone had forgotten to write down the name of the medication. On another cart, incomplete documentation was also identified, and the LPN stated there was no need to complete the resident’s name on the CMIS, indicating a misunderstanding or disregard of documentation requirements. Further review of additional carts showed similar issues. On one cart, an RN reported not having received recent education about narcotic management, despite the facility’s claim that all nurses had been educated. On another cart, the CMIS documented a total of 23 narcotic cards, while only 22 cards were physically present, and the RN Unit Manager acknowledged that the resident’s name should be documented and later reported that staff had told her they forgot to document the removal of one narcotic card. Another LPN described the expected process for narcotic counts and documentation, including documenting when medication cards are received or removed and ensuring all entries are complete and accurate, but the documented deficiencies showed that this process was not consistently followed. These findings, combined with QAPI meeting records that focused on reviewing the CMS Form 2567 and discussing corrective actions, demonstrate that the QAPI Committee did not effectively ensure that the planned corrective actions for narcotic documentation were fully implemented and sustained. The facility’s own QAPI policy describes a comprehensive, data-driven program intended to involve all departments and staff, focus on systems and processes, and use root cause analysis and performance improvement projects to achieve sustained improvement. It states that the Administrator is responsible for the Quality Assessment and Assurance Committee, which is to meet at least monthly, obtain data from multiple sources, and monitor and evaluate changes. However, the continued presence of incomplete and inaccurate narcotic documentation on multiple medication carts after the prior citation and Plan of Correction shows that the systems and monitoring described in the policy were not effectively applied to this issue. The deficiency centers on the gap between the facility’s written QAPI framework and the actual implementation and oversight of narcotic documentation practices on the units.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to accurately reconcile and continue an antipsychotic medication upon a resident’s readmission. The resident had diagnoses including major depressive disorder, generalized anxiety disorder, and other specified persistent mood disorders, and was discharged from the hospital with an active order for Lurasidone (Latuda) 20 mg to be given orally with supper. On readmission, the hospital discharge medication list clearly showed this Latuda order, but the facility’s electronic medical record and Order Summary Report for the readmission did not include Latuda, and the admission progress note section for medication reconciliation indicated there were no medications recommended by the hospital. As a result, the Latuda order was not entered into the physician orders on readmission and was not administered on the first two days after the resident returned. The medication was not started at the facility until two days after readmission, when it was initiated based on the hospital discharge paperwork. Interviews revealed that the DON expected the admitting nurse to call the physician, verify medications from the hospital discharge paperwork, review readmit medications, obtain new orders, and document any changes, but this process did not occur correctly for this resident’s Latuda order. An interview with the resident’s psychiatrist confirmed that he was not notified that the resident had missed two days of the antipsychotic medication and that it was important for medications to be administered as ordered. The facility’s medication reconciliation policy required reviewing hospital medication orders, noting any that needed clarification, and reviewing all medications with the physician when obtaining admission orders, as well as reviewing medications when residents return from ER visits or physician appointments, but this process was not followed for the Latuda prescription in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to promptly notify physicians of laboratory results for two residents, as required by federal regulations and the facility's own policies. For one resident, who had a history of a motor vehicle accident resulting in fractures and was experiencing respiratory symptoms, a stat D-dimer test was ordered by the physician. The laboratory result, which was significantly elevated, was received by the facility in the evening, but there was no documentation that the physician was notified until the following morning. Interviews with nursing staff and the Director of Nursing confirmed that the result was not communicated to the physician in a timely manner, and the delay was attributed to a lack of notification by the nurse on duty over the weekend. For another resident, laboratory results were received and reviewed by staff, but there was no documentation that the physician was notified or that the results were reviewed by the provider. The resident had a complex medical history, including diabetes, behavioral disturbances, and recent medication changes. Progress notes and provider documentation did not indicate that the abnormal lab results were communicated or addressed, despite facility policy requiring prompt notification and documentation of such communication. The facility's policy outlines a process for tracking, receiving, and notifying providers of laboratory results, including the use of a lab log and documentation of notification and any new orders. However, in both cases, the required steps were not followed, and there was a lack of documentation to show that physicians were promptly informed of critical or abnormal laboratory findings. This failure was confirmed through record review and staff interviews, demonstrating noncompliance with both regulatory requirements and internal procedures.

Plan Of Correction

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. F773 Lab Services Physician Order/Notify of Results 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1, the lab was reviewed by the physician no changes made to current order. Physician progress note completed that labs were reviewed for resident #1 and no changes made. Resident #2 discharged from the facility. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. Other current residents with lab orders in the last 30 days from were reviewed by the DON/Nursing Administration team to ensure review of lab results and physician notification with documentation was completed. 3. What measures will be put in place or what systematic changes will you make to ensure that deficient practice does not occur. Nurse leadership staff will be educated by the DON/designee regarding daily lab order review, and timely notification to physicians of results with supporting documentation by. Education completed by DON/designee to the licensed nurses regarding daily review of lab orders and timely notification of lab results reported to the physician of results with supporting documentation by. Education completed by the DON/designee to physicians for review of labs and notation that the lab was reviewed by. 4. How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? Random audits of lab orders, physician notification of lab results, and supporting documentation will be completed by the DON/designee on 20 residents, weekly x4 weeks then monthly x2 months. The results of the random audits will be presented to the QAPI committee monthly x3 months and as needed for review and follow-up recommendations as indicated. DON/designee regarding daily lab order review, and timely notification to physicians of results with supporting documentation by. Education completed by DON/designee to the licensed nurses regarding daily review of lab orders and timely notification of lab results reported to the physician of results with supporting documentation by. Education completed by the DON/designee to physicians for review of labs and notation that the lab was reviewed by. 4. How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? Random audits of lab orders, physician notification of lab results, and supporting documentation will be completed by the DON/designee on 20 residents, weekly x4 weeks then monthly x2 months. The results of the random audits will be presented to the QAPI committee monthly x3 months and as needed for review and follow-up recommendations as indicated.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that two residents received appropriate and adequate healthcare services due to delays in notifying the ordering provider of laboratory results. For one resident, who had a history of a motor vehicle accident resulting in fractures and was experiencing respiratory symptoms, a stat D-dimer test was ordered by the physician. The lab specimen was collected and the results, which were significantly elevated, were reported to the facility in the evening. However, there was no documentation that the physician was notified of these results until the following morning, resulting in a delay in further medical evaluation and intervention. For another resident, laboratory tests were ordered and completed, with results received and reviewed by staff. Despite this, there was no documentation that the physician or provider was notified of the results or that the results were reviewed by the provider. Progress notes and interviews confirmed the absence of documentation regarding provider notification or review of the lab results, even though the resident had a complex medical and behavioral history and was undergoing medication changes that warranted close monitoring. Interviews with nursing staff and the Director of Nursing revealed inconsistencies and gaps in the process for tracking, documenting, and communicating laboratory results to providers. Staff described reliance on verbal handoffs and incomplete use of lab tracking logs, and acknowledged that results were sometimes not promptly communicated to physicians. The facility's own policy required prompt notification of lab results to providers, but this was not consistently followed, as evidenced by the delays and lack of documentation in these two cases.

Plan Of Correction

N201 Right to Adequate and Appropriate Health Care Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. F773 Lab Services Physician Order/Notify of Results 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1, the lab was reviewed by the physician no changes made to current order. Physician progress note completed that labs were reviewed for resident #1 and no changes made. Resident #2 discharged from the facility. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. Other current residents with lab orders in the last 30 days from , were reviewed by the DON/Nursing Administration team to ensure review of lab results and physician notification with documentation was completed. 3. What measures will be put in place or what systematic changes will you make to ensure that deficient practice does not occur. Nurse leadership staff will be educated by the DON/designee regarding daily lab order review, and timely notification to physicians of results with supporting documentation by. Education completed by DON/designee to the licensed nurses regarding daily review of lab orders and timely notification of lab results reported to the physician of results with supporting documentation by. Education completed by the DON/designee to physicians for review of labs and notation that the lab was reviewed by. 4. How will the corrective actions be monitored to ensure the practice will not recur, what quality measures will be put into place? Random audits of lab orders, physician notification of lab results, and supporting documentation will be completed by the DON/designee on 20 residents, weekly x4 weeks then monthly x2 months. The results of the random audits will be presented to the QAPI committee monthly x3 months and as needed for review and follow-up recommendations as indicated. N0201

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to promptly notify physicians of laboratory results for two residents, resulting in a deficiency. For one resident with a history of fractures and essential hypertension, a stat D-dimer test was ordered after the resident experienced shortness of breath and was placed on oxygen. The D-dimer result, which was significantly elevated, was received by the facility but not communicated to the physician until two days later. During this period, there was no documentation of physician notification or follow-up regarding the abnormal result, despite the resident's ongoing symptoms and the critical nature of the test. In the second case, a resident with multiple diagnoses including diabetes, heart disease, and mood disorders had a valproic acid level ordered and collected. The laboratory result was received and reviewed in the system, but there was no documentation that the physician or psychiatric provider was notified of the result or that it was reviewed, despite facility policy requiring such notification and documentation. Progress notes and psychiatric notes did not reference the lab result, and the Director of Nursing confirmed the absence of documentation regarding review or notification. Interviews with nursing staff and the DON revealed inconsistencies in the process for tracking and communicating lab results. Staff described reliance on shift-to-shift communication and lab books, but there was no consistent use of a daily log or clear documentation of physician notification. Facility policy required prompt notification of lab results to physicians and documentation of such actions, but these procedures were not followed in the cases reviewed, leading to delays in physician awareness and potential delays in care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, clean, comfortable, and homelike environment due to ongoing pest sightings across all five wings. During a tour, live insects, including spiders and cockroaches, were observed in resident areas such as the dining room and linen closet. Multiple residents with intact cognition reported seeing pests, including roaches, in their rooms. Staff interviews confirmed occasional sightings of roaches, flying pests, and ants, with staff trained to record these in pest logs. Review of pest sighting logs documented numerous pest sightings in resident rooms and common areas over several months, including cockroaches, ants, and other bugs. The facility's pest control policy requires regular pest control services, food storage in airtight containers, daily trash removal, and prompt reporting and investigation of pest sightings. However, the Nursing Home Administrator acknowledged that pest reporting had increased and that the current pest control contractor was not meeting expectations. The absence of a housekeeping supervisor placed the responsibility for monitoring pest control on the administrator. Despite ongoing pest control efforts, the facility continued to experience pest issues, as confirmed by both staff and residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to inform the family of a resident's change in condition, specifically regarding a low potassium level and the initiation of potassium supplementation. The resident, who was admitted for respite and hospice care, had multiple diagnoses including transient ischemic accident, congestive heart failure, cerebrovascular accident, stage 4 chronic kidney disease, and hypertension. Laboratory results showed a potassium level below the acceptable range, and the resident was subsequently started on potassium as ordered by the physician. However, there was no documentation in the progress notes indicating that the family was notified of the abnormal lab result or the new medication. During interviews, the DON confirmed that the facility's policy requires prompt notification of the resident's representative when there is a significant change in the resident's condition or when new medications are started. The DON acknowledged that the family should have been notified of the low potassium and the initiation of potassium therapy. Review of the facility's policy further supported the expectation for family notification and documentation in the medical record, which was not observed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from abuse by a staff member, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident with severe cognitive impairment. The resident, who had a history of dementia, anxiety, and psychosis, was observed to have been pinched by a staff member after an altercation. The incident was reported by another staff member who witnessed the CNA pinching the resident in retaliation after the resident had hit the CNA. This resulted in visible bruising on the resident's arms, which was consistent with the reported abuse. The resident's medical history included severe cognitive impairment, aggressive behavior, and a tendency to wander, which required supervision and specific interventions to ensure safety. The resident's care plan highlighted the need for staff to intervene to protect the rights and safety of others, and to approach the resident in a calm manner. Despite these measures, the incident occurred, indicating a failure in adhering to the care plan and abuse prevention policies. The facility's policy on abuse prevention mandates immediate reporting of any alleged violations to the appropriate authorities. However, the incident involving the resident and the CNA was not prevented, and the staff member involved was only suspended after the fact. The facility's records showed that the CNA had received abuse training approximately one month prior to the incident, yet the abusive behavior still occurred, highlighting a deficiency in the facility's ability to prevent and address abuse effectively.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide trauma-informed care for a resident following an allegation of abuse. The resident, who had a history of moderate cognitive impairment and a previous molestation experience, reported feeling molested by a volunteer. Despite the resident's family confirming a history of molestation, the facility did not conduct a trauma screening after the allegation, which was a requirement according to their policy. The resident had been admitted with diagnoses including Parkinson's disease, dementia, and anxiety disorders. Prior to the incident, the resident had expressed concerns about being drug tested or molested during a urine collection procedure. The facility's records showed that the last PTSD/Trauma Screening was conducted nine months before the allegation, and it did not indicate PTSD at that time. However, the facility's policy required rescreening when new trauma indicators arose, which was not done in this case. Interviews with facility staff, including the Risk Manager, Director of Nursing, and Social Service Director, revealed a lack of awareness and communication regarding the resident's history and the need for a trauma screening. The facility's policy on trauma-informed care emphasized the importance of addressing past trauma and developing individualized care plans, but these steps were not taken following the resident's allegation.