Alameda Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Burbank, California.
- Location
- 925 W. Alameda Ave., Burbank, California 91506
- CMS Provider Number
- 555690
- Inspections on file
- 51
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Alameda Care Center during CMS and state inspections, most recent first.
A resident with dementia, encephalopathy, and DM experienced episodes of blood‑tinged urine, but the COC form showed an inaccurate time for family notification, documenting contact before the first reported episode. An RN and an LVN performed straight catheterizations on two occasions to obtain urine for UA and C&S, yet neither invasive procedure nor the resident’s tolerance was documented in the medical record. Later, UA and urine culture results indicating possible infection were reported by the lab, but there was no documentation that the physician was notified of these results, contrary to the facility’s charting policy requiring complete, accurate documentation of treatments, services, and provider notifications.
A resident with dementia, encephalopathy, diabetes, and total incontinence experienced two episodes of blood‑tinged urine during a night shift, which were reported by a CNA to an LVN. Although hematuria was documented at 3 a.m. and again at 6:30 a.m., the physician was not notified until the oncoming RN contacted the physician after 7 a.m. Later, a urinalysis with culture and sensitivity ordered for this resident was reported to the facility in the evening, but the physician was not notified until the following afternoon, as shown by a delayed text of the lab report from the facility phone. Multiple nurses and the DON stated that the physician should have been notified immediately of both the hematuria and the lab results, and facility policy requires prompt physician notification for changes in condition such as hematuria and for laboratory reports.
A resident with dementia, encephalopathy, diabetes, and documented severe cognitive impairment experienced episodes of blood-tinged urine, which were reported by a CNA to an LVN and led to physician orders for urinalysis with culture and sensitivity and possible straight catheterization for urine collection. Although the urine specimen was obtained via straight catheterization and the resident did not have an indwelling catheter, the resulting care plan documented interventions for monitoring and caring for a Foley catheter, including catheter care every shift and maintaining catheter alignment. The DON later confirmed that the resident never had an indwelling catheter and that the care plan was not individualized or accurate, despite facility policy requiring individualized care plans based on resident needs and physician orders.
Surveyors found that staff failed to provide ordered skin treatments and obtain or act on dermatology consult orders for three residents with rashes. One resident with severe cognitive impairment had physician-ordered hydrocortisone cream for chest and abdominal rashes, but multiple treatment entries on the TAR were left blank, and nursing leadership confirmed this meant the treatment was not given. Another cognitively impaired resident with generalized dermatitis had an order for clotrimazole-betamethasone cream, yet no treatments were documented for nearly two weeks after the order lapsed, and an existing dermatology consult order was never acted upon for months while only a wound care NP followed the case; the NP reported being told by facility leadership not to order scabies testing or aggressive treatment. A third resident with rashes on multiple body areas had an order for dermatology consultation and ongoing rash documentation, but dermatology was not notified and the resident was not seen by a dermatologist until about a month later, when a dermatologist finally visited to evaluate multiple residents with rashes.
During a scabies outbreak, the facility failed to follow its infection control, skin assessment, and communicable disease reporting policies. A resident was readmitted with rashes, but weekly rash assessments were not documented, and the wound care provider and dermatologist were not properly notified despite existing orders and care plan interventions. When two residents ultimately tested positive for scabies at acute care hospitals, the facility did not document one of the notifications in the medical record and did not report the second confirmed case to the State Survey Agency, contrary to its outbreak and unusual occurrence policies. Several exposed residents, including a roommate and dining contacts, did not receive documented daily skin assessments as required by facility guidelines, and a staff member with a rash was treated but not evaluated with a skin scraping or tracked via a line list of resident contacts. The facility also did not provide training or competency validation on skin scraping for treatment nurses before they performed the procedure.
Surveyors found that the facility did not develop or implement person-centered care plans for two residents with significant behavioral and skin integrity needs. One resident with dementia and Alzheimer’s disease exhibited new spitting and aggressive behavior during showering, which was reported by staff but never incorporated into a behavior care plan. Another resident with a pressure ulcer was observed using a wedge pillow to offload the sacral area, yet there was no care plan addressing this device, and staff confirmed its absence. The same resident repeatedly refused repositioning, with CNAs reporting refusals to an LVN, but no care plan was created to address the refusal, and the issue was not escalated to an RN, despite facility policies requiring assessment, documentation of refusals, and comprehensive, measurable care plans for such problems.
A resident with severe cognitive impairment, incontinence, and existing sacral and heel pressure injuries did not consistently receive ordered daily wound treatments, as multiple entries on the TAR were left blank without documented reasons, despite detailed physician orders and facility policy requiring verification and documentation of wound care. Prior to transfer to a hospital, an RN completed transfer paperwork but only inspected the sacral area and did not perform or document a full head-to-toe skin assessment, contrary to the facility’s transfer and pressure injury prevention policies. Additionally, staff used a wedge pillow to offload the resident’s sacral area without obtaining a physician order, even though facility policy required physician-ordered pressure reduction surfaces and device selection to minimize tissue damage.
The facility failed to timely report an allegation that a CNA slapped a cognitively impaired resident during a supervised shower. The resident, who had dementia, Alzheimer's disease, and generalized weakness and required staff supervision for bathing, became agitated and spit at the CNA during the shower. A student later told another CNA that the CNA had slapped the resident in the face. That CNA did not directly report the allegation to the ADM, despite facility policy requiring mandated reporters to ensure all alleged abuse is reported to the state agency, Ombudsman, and law enforcement within two hours. The ADM later confirmed the allegation had not been reported as required and stated that failure to report could cause psychological distress and potential further abuse for the resident.
A resident with severe cognitive impairment, incontinence, and existing pressure injuries had inconsistent and inaccurate skin documentation, including a Skin Issues record that listed multiple stage 3 and stage 4 pressure ulcers when staff later confirmed only one stage 4 sacrococcyx ulcer was present. Additionally, the MAR showed that LVNs documented administration of Depakote, Mirtazapine, and Potassium on days when the resident was actually hospitalized and not in the facility. Staff interviews confirmed that these entries were incorrect and not in accordance with facility policies requiring accurate, complete charting and verification of resident presence and identity before documenting medication administration.
The facility failed to follow professional standards and its own scabies policies for multiple residents with rashes and pruritus. One resident with a history of dermatitis, diabetes, and Parkinson’s disease had progressively spreading, itchy rashes documented over several months without timely skin scraping or dermatology consultation, and was later confirmed positive for scabies. The facility did not promptly identify and assess all exposed residents, initially limiting its contact list to roommates and only later adding dining companions, with no documented assessments for other contacts. A roommate with generalized rashes received prophylactic permethrin and contact isolation, but skin scraping was ordered and performed only after treatment, and there was no evidence of dermatology evaluation before or during this process. Several direct-care staff, including a treatment nurse, CNA, and LVN, were not informed of the confirmed scabies case until days after the facility learned of the result, and a CNA was observed providing care to an exposed resident under enhanced barrier precautions without PPE. Leadership acknowledged delays in skin scraping, lack of timely assessments of exposed residents, and reliance on absent dermatology services, while a NP reported management pushback on ordering skin scrapings due to concerns about outbreak designation and fines.
The facility failed to ensure that treatment nurses and an IPN were competent to perform skin scraping procedures used to help diagnose skin conditions. Employee file reviews showed that competency assessments completed for these nurses did not include skin scraping, and there was no documentation that this skill was assessed upon hire or annually. The DSD and DON acknowledged that skin scraping was not part of the nurses’ competency evaluations and that, without this assessment, the procedure might not be performed correctly, potentially affecting diagnostic accuracy, despite facility policies and scabies control guidelines requiring appropriate clinical skills and demonstrated competency before assignment.
Staff failed to maintain accurate and timely medical records for several residents, including one who was documented as receiving topical treatment after being transferred to a hospital, and multiple residents who underwent STAT skin scrapings for dermatitis. In these cases, the nurse who actually performed the procedures did not document them on the TARs, while another nurse who only observed later signed the TARs days after the procedures and guessed the times. One resident’s initial admission assessment documented no skin issues, but a reassessment the next day showed widespread rashes, and the subsequent STAT skin scraping was not properly recorded at the time it was performed. These actions conflicted with facility policies requiring complete, objective, and accurate documentation of treatments, including the date, time, and identity of the staff providing care.
A resident with dementia and high fall risk was left unsupervised at a dining room entrance and subsequently fell. After the incident, the facility did not promptly update the care plan, complete a Fall Risk Evaluation, or provide required 72-hour monitoring. Documentation and notifications to the MD and responsible representative were also delayed, contrary to facility policy.
A resident with dementia and high fall risk experienced a fall after being left in the dining room entrance by a CNA. Staff interviews and record review showed that required notifications to the MD and resident representative were not made, and the Change in Condition assessment and monitoring were not completed until several days later, contrary to facility policy.
A facility did not report an allegation of staff-to-resident physical abuse to required authorities after a staff member claimed a CNA pushed a resident with dementia and high fall risk. The administrator did not report the incident, citing lack of injury and considering the allegation as hearsay, despite facility policy requiring immediate reporting of suspected abuse.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, and serve food according to professional standards, resulting in a deficiency related to food safety and handling.
Surveyors observed that facility trash bins were repeatedly overfilled and left uncovered, with cardboard bins open and overflowing. Both the DSS and DON confirmed that these conditions did not comply with facility policies requiring covered waste containers and timely disposal, as outlined in the waste control and pest control procedures.
A facility failed to create and implement a care plan for a resident exhibiting disrobing behavior, despite repeated incidents and staff awareness, and did not document required monitoring for adverse effects in a resident receiving carbidopa-levodopa for Parkinson Disease. These deficiencies were confirmed by staff interviews and record reviews, showing a lack of adherence to person-centered care planning and monitoring policies.
Licensed nursing staff failed to rotate subcutaneous insulin injection sites for two residents with diabetes, administering repeated injections in the same areas despite physician orders, facility policy, and manufacturer guidelines requiring site rotation. This practice was confirmed through record review and staff interviews, and was inconsistent with professional standards of care.
Surveyors found that several residents with cognitive impairments and high fall risk had furniture or equipment placed on their fall mats, and two residents had bed controllers with exposed wires. Staff and the DON confirmed these practices compromised resident safety and did not follow facility policies or manufacturer instructions, which require keeping mats clear and equipment in good repair.
The facility failed to ensure proper pharmaceutical services by not documenting the disposition of an extra Augmentin tablet for a resident, administering carbidopa-levodopa ER at the wrong time for another resident with Parkinson's disease, and not reconciling a controlled medication emergency kit in a medication room at each shift change, as required by facility policy.
A Pharmacy Consultant did not identify or report irregularities in the monthly drug regimen reviews for two residents. One resident prescribed valproic acid for bipolar disorder did not have specific behavior monitoring in place, and another resident on carbidopa-levodopa for Parkinson Disease lacked documentation of monitoring for adverse effects. The consultant acknowledged these omissions, and facility policies required such monitoring and reporting to the DON and prescriber.
A resident prescribed carbidopa-levodopa for Parkinson’s Disease was not monitored for adverse effects as required by their care plan and facility policy. Review of the MAR showed no documentation of monitoring, and both nursing staff and the DON confirmed the absence of required monitoring for side effects such as dyskinesia. This failure to implement the care plan and follow policy resulted in noncompliance with medication monitoring standards.
A resident received four medications at times not consistent with physician orders, as an LVN administered famotidine, buspirone, hydrochlorothiazide, and losartan outside the facility's required 60-minute window. This resulted in four medication errors out of 26 opportunities, leading to a medication error rate of 15.38%, which was confirmed by both the LVN and DON as not following facility policy and the '5 rights' of medication administration.
Surveyors found that two residents with diabetes received subcutaneous insulin injections without proper rotation of injection sites, as required by physician orders, facility policy, and manufacturer guidelines. Nursing staff and the DON confirmed that insulin was repeatedly administered in the same anatomical areas, and records showed multiple instances of this practice. This failure constituted a significant medication error.
Surveyors found that two residents' inhalation medications were not labeled with open dates as required by manufacturer instructions and facility policy, making it impossible to determine if the medications were expired. An LVN and the DON confirmed that multi-dose products must be labeled with the date opened, and the lack of labeling prevented staff from verifying the medications' effectiveness.
Several residents with medical conditions requiring No Added Salt (NAS) diets were provided with extra salt packets on their meal trays, despite clear dietary orders and facility policy prohibiting this. Both residents with intact and impaired cognition were affected, and staff interviews confirmed that kitchen staff did not check tray tickets for NAS diet orders, resulting in the failure to follow prescribed therapeutic diets.
The facility failed to ensure complete and accurate medical records for three residents, including missing documentation of informed consent verification for psychotropic medications and failure to record the administration of an antibiotic in the MAR. Staff and leadership confirmed these omissions, resulting in incomplete records regarding treatment discussions and medication administration.
Personal belongings, including bags, a sweater, a cellphone, and sunglasses, were found in the clean laundry room by a laundry staff member, contrary to facility infection control policies. The items were observed near clean linens, and staff interviews confirmed that personal belongings are not allowed in this area, as lockers are provided elsewhere for storage. Facility leadership acknowledged the failure to maintain the cleanliness and infection control standards required for the laundry area.
The facility did not have a program in place to monitor antibiotic use, as required. Surveyors found no evidence of a system to track or evaluate antibiotic administration to residents.
Several residents were found with unsafe equipment, including a fall mat with peeling covers and bed remote controls with frayed or exposed wires. Staff and the DON confirmed these issues were not identified or reported as required, despite facility policies mandating regular checks and maintenance to ensure a safe environment.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
Residents were not fully informed or did not fully understand their health status, care, and treatments, as they were not provided with sufficient information about their medical condition and the care or treatments being administered.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in a deficiency related to medication management.
Two residents did not receive pressure ulcer prevention interventions as ordered, including the failure to apply heel protectors for a resident with a stage three sacral ulcer and not setting a low air loss mattress according to another resident's weight, despite clear physician orders and facility policy.
A resident with severe cognitive impairment and multiple diagnoses did not receive required face-to-face visits from the attending physician or psychiatrist, as all visits were conducted by nurse practitioners instead. Facility records lacked documentation of direct physician visits, and staff confirmed that the mandated visits by the AP and Psych MD did not occur, contrary to facility policy.
Two residents were not aware of the location or availability of the facility's latest survey results, as the survey binder was stored in an inaccessible location with an unreadable label. Staff confirmed that residents were only told to ask for the binder, rather than having direct access, which did not align with facility policy requiring survey results to be easily accessible.
Nineteen rooms were found to provide less than the required 80 square feet per resident, with three-bed rooms ranging from 195 to 238 square feet. Staff and residents reported no issues with space, and observations confirmed adequate movement and care provision, but the facility's own policy and federal requirements for room size were not met.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was subjected to undignified treatment when a CNA raised her voice and threw a spoon back at the resident after the resident became aggressive during lunch. This response was inconsistent with facility policy requiring staff to treat residents with dignity and sensitivity, especially those with cognitive impairments.
The facility failed to ensure call lights were within reach for two residents, potentially delaying care. One resident with Alzheimer's and cognitive deficits had their call light on the floor, while another with COPD and muscle weakness had their call light tangled and inaccessible. Staff failed to notice or correct the issue, and the DON acknowledged the oversight, which violated the facility's policy requiring call lights to be accessible.
The facility failed to notify the physician when two residents experienced changes in their skin condition, including rashes and itchiness. One resident was observed with raised, open, and red skin rashes, while another reported persistent itchiness affecting sleep. The LVN did not notify the physician, contrary to facility policy requiring prompt notification for any change in condition.
Two residents with severe cognitive impairments experienced unmanaged skin conditions due to the facility's failure to notify the physician of changes. One resident had a rash and itchiness, while the other suffered from persistent itchiness affecting sleep. Despite facility policy, staff did not inform the MD, leading to potential risks for both residents.
The facility failed to maintain an effective infection control program during an IGAS outbreak, as high touch areas at two nursing stations were not routinely disinfected. Disinfection logs showed multiple instances where LNs did not document their activities, suggesting non-compliance with disinfection protocols. Interviews confirmed the outbreak and the importance of regular disinfection, but the absence of documentation implied it was not done, leading to a deficiency in the infection control program.
A resident with Alzheimer's and severe cognitive impairment experienced a delay in receiving a STAT X-ray after a fall, which was ordered to assess a suspected fracture. The facility's staff did not follow up with the radiology provider, resulting in the X-ray not being conducted within the required timeframe. The resident was later transferred to a hospital, where the fracture was confirmed.
The facility was found to have several deficiencies in its food storage and preparation practices, including chipped refrigerator shelves, unclean freezers, and improper storage of dented cans. Additionally, the knife container and scoops were not properly cleaned, and food carts had dried spills. A resident's food from home was not labeled, posing a risk of incorrect diet administration. These issues could lead to harmful bacteria growth and cross-contamination, potentially causing foodborne illnesses among residents.
The facility lacked a comprehensive policy for the safe storage and handling of food brought by family and visitors, potentially affecting 78 residents. The existing policy discouraged outside food due to safety concerns but allowed it as a resident's right. The Registered Dietitian and Director of Nursing acknowledged the policy's lack of specific storage guidelines, which could lead to emotional changes and weight loss among residents.
The facility failed to maintain cleanliness in the trash area, with observations revealing soiled utensils, trash, and liquid drippings around the dumpster. Interviews with the Dietary, Maintenance, and Housekeeping Supervisors confirmed the lack of proper cleaning, despite facility policies requiring clean surroundings and covered receptacles. This posed a potential infection risk to all residents.
The facility failed to maintain sanitary conditions in the food services department, as a fly was observed landing on a can opener and a baked good. The Dietary Supervisor acknowledged the fly could have entered from the breakroom or office and expressed concern about potential germ transmission. The facility's Pest Control Policy requires an effective pest control program to keep the building free of insects.
The facility failed to ensure call lights were available and within reach for five residents, leading to a deficiency in accommodating resident needs. Residents with cognitive impairments and mobility issues were observed without accessible call lights, risking delayed care and potential accidents. Staff confirmed the importance of having call lights within reach, as per facility policy, to prevent unassisted movements and falls.
The facility failed to maintain and document advance directives (ADs) for three residents, violating their rights to have their healthcare wishes respected. Despite indications of executed ADs, these documents were missing from the residents' charts, as confirmed by staff interviews and record reviews. This deficiency could lead to conflicts with the residents' healthcare preferences.
Failure to Maintain Accurate and Complete Medical Record for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with significant cognitive impairment and multiple medical diagnoses. The resident was admitted with encephalopathy, unspecified dementia, and diabetes mellitus, and was documented as lacking capacity to make decisions, with severely impaired cognitive skills and total bowel and bladder incontinence. On a change of condition (COC) form dated 2/13/2026, a CNA reported to an LVN that the resident had blood‑tinged urine in their diaper at 3 a.m. and again at 6:30 a.m. However, the COC also showed that the family member was notified at 12 midnight, a time that preceded the first documented episode of blood‑tinged urine. During review, the DON confirmed that the midnight entry was not an accurate time and stated that the LVN should have documented the actual time the family member was called. The facility also failed to document invasive nursing procedures performed to obtain urine specimens for ordered urinalysis and culture and sensitivity testing. Physician orders dated 2/13/2026 included urinalysis with culture and sensitivity and allowed straight catheterization if a clean‑catch specimen could not be obtained. An RN stated that on 2/13/2026 she, with assistance from an LVN, performed straight catheterization on the resident to obtain a urine sample, but there was a labeling issue with the specimen. The assisting LVN confirmed she helped with the straight catheterization on 2/13/2026 and that she later performed another straight catheterization on 2/14/2026 after learning the specimen should have been placed in a tube instead of a cup. The LVN acknowledged that neither the initial nor the repeat straight catheterization was documented in the resident’s medical record, despite recognizing that these were invasive procedures and that documentation of how the resident tolerated them was important. The DON confirmed that these procedures should have been documented and that the facility failed to record two invasive procedures in the resident’s record. Additionally, the facility did not document physician notification of the resident’s laboratory results. Laboratory reports showed that the urine specimen was received on 2/17/2026, with urinalysis results reported to the facility that evening and urine culture results reported three days later. Review of the resident’s progress notes for those dates revealed no documentation that the physician was notified of either the urinalysis or urine culture results. An RN stated she worked earlier shifts on both days and that LVNs on later shifts should have received the faxed lab results and sent them to the physician, and she acknowledged that the results may have indicated signs of a urinary infection and that nurses should have documented physician notification. The DON confirmed there was no documented evidence of physician notification for these lab results and stated that failing to document meant physician notification was not done, and that the facility’s charting and documentation policy—which requires complete, accurate, objective documentation of services, procedures, and notifications—was not followed, resulting in an incomplete and inaccurate medical record for the resident.
Failure to Promptly Notify Physician of Hematuria and Abnormal Urinalysis Results
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of a resident’s change in condition and subsequent abnormal laboratory results. The resident was admitted with diagnoses including unspecified encephalopathy, unspecified dementia, and diabetes mellitus, and was documented as lacking capacity to make decisions, with severely impaired cognitive skills and complete bowel and bladder incontinence. On the night in question, a CNA reported to an LVN at 3 a.m. that the resident’s diaper contained blood‑tinged urine. The LVN documented hematuria with no associated pain or burning. At 6:30 a.m., the CNA reported a second episode of blood‑tinged urine. Despite these findings, the physician was not notified until 7:13 a.m., when the oncoming RN contacted the physician after being informed that hematuria had occurred at 3 a.m. and again at 6:30 a.m. Interviews with nursing staff and the DON confirmed that the LVN on duty should have notified the physician immediately upon the first observation of blood‑tinged urine at 3 a.m., in accordance with facility expectations. RN 2, LVN 2, RN 1, and the DON each stated that the physician should have been informed right away of the hematuria, and that there was a delay in physician notification. The facility’s Change in Condition policy, which lists hematuria and laboratory reports as changes requiring prompt handling, specifies that the physician shall be called promptly upon any change in condition, with documentation of all contacts or attempts. A second failure occurred related to the resident’s urinalysis with culture and sensitivity, which had been ordered on the same date as the hematuria. The laboratory results were reported to the facility on 2/17/2026 at 7:37 p.m. RN 1, who worked only until 3 p.m. that day, stated that after her shift the assigned LVNs should have received any faxed lab results and sent an electronic message with the results to the physician that same day. Review of facility phone text messages with the DON showed that a picture of the resident’s urinalysis result was not sent to the physician until the following afternoon, and there was no indication of physician notification on the date the results were received. The DON stated that LVNs should have notified the physician of the urinalysis result when it was received so the physician could proceed with an appropriate plan of care, and acknowledged there was a delay in physician notification.
Failure to Accurately Individualize Care Plan for Resident With Hematuria
Penalty
Summary
The facility failed to develop and implement an accurate, person-centered care plan for a resident who experienced hematuria. The resident was admitted with diagnoses including unspecified encephalopathy, unspecified dementia, and diabetes mellitus, and was documented as lacking capacity to make decisions and having severely impaired cognitive skills. The MDS indicated the resident was always incontinent of bowel and bladder. On one date, a Change of Condition note documented that a CNA reported to an LVN that the resident had blood-tinged urine in their diaper on two occasions during the early morning. A physician order was obtained for a urinalysis with culture and sensitivity, with permission to perform straight catheterization for urine collection if a clean catch specimen could not be obtained. The resident’s care plan, initiated in response to the hematuria, documented interventions related to monitoring and caring for an indwelling Foley catheter, including monitoring the catheter and changing it or the bag as ordered, providing Foley catheter care every shift, and maintaining proper alignment of the Foley catheter. However, interview and record review confirmed that the resident did not have an indwelling catheter and that urine for the ordered tests was obtained via straight catheterization. The DON acknowledged that the care plan was not individualized or accurate, stating that the resident never had an indwelling catheter and that the care plan should have reflected the use of straight catheterization and been consistent with the resident’s actual needs and orders, in contrast to the facility’s policy requiring individualized care plans.
Failure to Provide Ordered Rash Treatments and Timely Dermatology Consultations
Penalty
Summary
The deficiency involves the facility’s failure to provide skin treatments and specialty consultations as ordered, and to obtain necessary physician orders, for three residents with rashes. For one resident with schizoaffective disorder, dementia, and chronic hepatitis B, a skin reassessment on 1/15/2026 documented rashes on the chest and abdomen, and a physician order was in place to cleanse the rash and apply hydrocortisone 1% cream on the day and evening shifts for four weeks. Review of the Treatment Administration Record (TAR) for 1/2026 showed blank entries for the ordered treatment on multiple shifts, and both the Registered Nurse Supervisor and the MDS nurse stated that blank TAR entries meant the treatment was not provided or signed. Facility policy on administering medications required that medications and treatments be administered in accordance with prescriber orders and documented with date, time, dosage, route, and the initials/signature of the person administering. A second resident, admitted with Parkinson’s disease, dementia, and unspecified dermatitis, had a physician order dated 10/2/2025 to cleanse generalized rashes on the bilateral upper and lower extremities and chest with normal saline and apply clotrimazole-betamethasone cream on day and evening shifts for four weeks. Wound care NP notes on 10/28/2025 and 11/11/2025 documented generalized dermatitis and a plan to cleanse with normal saline and apply clotrimazole 1% and betamethasone 0.05% cream twice daily. However, the November 2025 TAR showed no treatment documented from 11/1/2025 to 11/13/2025. Treatment Nurse 1 stated that the resident still had rashes during that period, that the treatment order had not been renewed, that there was no documented physician order for the rash during those dates, and that no treatment was provided. The RNS and MDS nurse confirmed that without a physician order and documentation, the rash treatment was not provided for 13 days, despite facility policies on administering medications, non-pressure sore management, and alteration in skin integrity that required assessment, physician notification, and treatment orders for skin alterations. The same resident had an order on 5/17/2025 for a dermatology consultation and follow-up treatment as indicated, but wound care notes from 2/25/2025 through 12/25/2025 repeatedly documented generalized fungal or unspecified dermatitis without any documentation that a dermatologist evaluated the resident. The Infection Preventionist confirmed that the resident was transferred to an acute care hospital on 1/16/2026 with body rashes, and Treatment Nurse 1 stated the resident was never seen by a dermatologist and was only seen by the wound care NP. The RNS stated that the dermatologist did not assess the resident’s rashes from the date of the order until transfer, a period of almost eight months, and that the NP was a wound care specialist, not a dermatologist. The NP reported that he had raised the issue of scabies testing and treatment with the DON before 12/25/2025 but was told not to order scabies tests or aggressive treatment because of concerns about a potential scabies outbreak and staffing, and that the facility intervened to prevent him from ordering scabies tests and treatment. Facility wound care policy required verification of a physician’s order for wound procedures, and the submitted scabies prevention guideline called for access to clinicians experienced in recognizing scabies and confirmation by skin scraping. A third resident, admitted with cerebral infarction, dementia, and pneumonia, had an order dated 12/25/2025 for a dermatology consult and follow-up treatment as indicated. A skin reassessment on 12/26/2025 documented rashes on the bilateral upper and lower extremities, chest, and back, and a care plan dated 1/5/2026 included an intervention to notify dermatology of non-response. Skin rash reports on 1/9/2026 and 1/24/2026 documented ongoing rashes, and the TAR for 1/2026 showed the resident received triamcinolone twice daily for dermatitis throughout the month. Treatment Nurse 1 stated this resident was the roommate of the resident later confirmed with scabies in the hospital, had rashes since 12/26/2025, and was not seen by a dermatologist until 1/26/2026, when the dermatologist came to evaluate multiple residents with rashes after the other resident’s positive scabies test. The RNS stated the facility should have followed the physician order for dermatology consultation and that a one-month delay in notifying dermatology could worsen the resident’s rashes. Treatment Nurse 1 further stated that RNs obtain dermatology consultation orders and notify dermatology by fax or phone, but she did not call because the facility did not have a dermatologist until 1/26/2026. Facility policies on non-pressure sore management and change in condition required physician notification and follow-through when residents developed rashes, and the RNS stated that when this resident developed rashes on 12/26/2025, a change in condition should have been created and the physician order followed.
Failure to Implement Scabies Outbreak Control, Skin Assessment, and Reporting Procedures
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its infection prevention and control program, skin assessment policies, and communicable disease reporting procedures during a scabies outbreak. One resident was readmitted with documented rashes on the chest and abdomen, but weekly Skin Rash Reports were not initiated or completed after the readmission, despite facility policies requiring weekly skin inspections and documentation of non‑pressure skin conditions and rashes. Treatment nurses and other nursing staff acknowledged that weekly rash assessments were not performed or documented on multiple Thursdays, and the Minimum Data Set nurse and Resident Nursing Supervisor confirmed that the facility’s policies on Prevention of Pressure Injuries/Skin Breakdown, Body Checks, and Alteration in Skin Integrity were not followed. Staff stated that without weekly rash documentation, the progress of the rash and effectiveness of treatment could not be evaluated, and that the resident’s rashes could worsen. The facility also failed to notify the wound care provider and dermatologist and to document key clinical information related to the scabies outbreak. After the resident’s readmission with rashes, there was no documentation that the wound care physician or nurse practitioner was informed, and no subsequent wound care notes were found. The nurse practitioner, infection preventionist, MDS nurse, RN, and Resident Nursing Supervisor all stated that the wound care provider should have been notified and that there was no documentation of such notification. Although there was an order and care plan intervention for a dermatology consult, treatment nurses did not ensure that the dermatologist who visited on two separate dates was informed of this resident’s rashes, and the dermatologist’s progress notes showed that only nine other residents were evaluated and treated. The administrator and infection preventionist stated that the dermatologist should have been notified of all residents with rashes, including this resident. Additionally, when the facility was notified by an outside hospital that this resident tested positive for scabies, the marketer relayed the information verbally to the administrator, but there was no documentation of this notification in the resident’s medical record, contrary to the facility’s Charting and Documentation policy requiring complete and accurate documentation. The facility did not properly recognize and report the scabies outbreak to the State Survey Agency and did not complete required surveillance and assessments for exposed residents and staff. One resident had previously tested positive for scabies at another hospital, and the infection preventionist stated the facility was informed of this result. When a second resident later tested positive for scabies at a different hospital, the administrator acknowledged being notified but did not report this second confirmed case to the State Survey Agency, despite facility policies and county guidelines defining an outbreak as two or more cases and requiring reporting within 24 hours. The administrator later acknowledged that the facility’s Scabies: Prevention and Control policy and Unusual Occurrences policy were not followed. The infection preventionist and Resident Nursing Supervisor confirmed that the facility was considered to be in a scabies outbreak and that such outbreaks should be reported. The facility also failed to perform and document daily skin assessments on four residents who were identified as exposed through room sharing and dining contact, despite facility guidelines and policies requiring daily skin assessments on exposed residents and daily assessments for roommates of infected residents until the case was resolved. The deficiency further includes failures related to staff training, competency, and case tracking. The Director of Staff Development/Infection Preventionist and Resident Nursing Supervisor stated that no in‑service education, training, or competency evaluation on skin scraping was provided to the treatment nurses before they performed skin scrapings on residents during the outbreak. They acknowledged that the nurses were not checked for competency and that training should have been done before skin scraping procedures were carried out. Additionally, a certified nursing assistant who developed lower back rashes was treated with Elimite cream but was not assessed for scabies via skin scraping, and the facility did not develop a line list identifying this staff member’s resident contacts for the six weeks prior to symptom onset, as required by the facility’s submitted Acute Communicable Disease Control Program–Scabies Prevention and Control Guidelines. These guidelines also required preparation of line lists for symptomatic healthcare workers and residents and daily skin assessment documentation on all exposed residents, which the facility did not complete.
Failure to Develop Person-Centered Care Plans for Behavior, Pressure Ulcer Interventions, and Treatment Refusals
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans addressing specific behaviors and clinical needs for two residents. For one resident with dementia, Alzheimer’s disease, and generalized weakness, the admission record showed the resident was admitted in September 2025, and a subsequent H&P documented that the resident lacked capacity to understand and make decisions. An MDS assessment later indicated the resident could sometimes understand others and make self-understood and required supervision with toileting and showering. Progress notes from early January 2026 documented that this resident became verbally and physically restless and had an anger outburst before a shower, then became physically aggressive during the shower, yelling and spitting at a CNA. Multiple staff, including the DSD and Administrator, confirmed that the resident had spit at the CNA, and the MDS nurse stated the resident had behaviors of spitting and kicking but acknowledged there was no care plan addressing the spitting behavior. The facility also failed to develop a care plan for another resident’s use of a wedge pillow and for that resident’s refusal of repositioning. During observation in early February 2026, a wedge pillow was seen on the resident’s left side in the room. The treatment nurse explained that the wedge pillow was used to keep the resident’s sacral area off the bed to prevent worsening of a pressure ulcer, but confirmed there was no care plan for the use of the wedge pillow. The MDS nurse and RN 1 both reviewed the care plans and stated there was no care plan for the wedge pillow, and the MDS nurse stated there should be a care plan for its use because it guides nurses on how to care for the resident. The RN supervisor stated that interventions provided to address the resident’s pressure ulcer should have a care plan, and that without a care plan, nurses would not be able to evaluate if the intervention was effective and it could possibly cause worsening of the pressure ulcer. In addition, the same resident was described by the treatment nurse as noncompliant with repositioning, and other staff confirmed ongoing refusals. The MDS nurse stated there was no care plan developed for the resident’s refusal to be repositioned and that a care plan helps minimize further decline or prevent worsening of pressure ulcers, and that without such a care plan the resident’s wound can worsen. An LVN reported that CNAs had informed her of the resident’s refusal to be repositioned; she spoke with the resident, who continued to refuse, but she did not develop a care plan and did not report the noncompliance to an RN, stating that RNs develop care plans. The LVN stated a care plan should have been developed and that without a care plan for refusal of repositioning, the resident’s wound could worsen. The RN supervisor similarly stated that a care plan should have been developed to address the resident’s refusal of repositioning to ensure resident rights for refusal were followed and to prevent worsening of the pressure ulcer. Facility policies on behavioral assessment, pressure ulcer prevention, wound care, and comprehensive person-centered care plans all required assessment of new behaviors, individualized interventions, documentation of refusals, and development and revision of care plans with measurable objectives and timeframes, which were not followed in these instances.
Failure to Provide Ordered Wound Care, Complete Transfer Skin Assessment, and Obtain Order for Wedge Pillow
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with physician orders and facility policy for a cognitively impaired resident with existing pressure injuries. The resident was admitted with metabolic encephalopathy, dementia, and pressure ulcers to the sacral area and left heel, and was documented as severely impaired in decision-making, fully dependent for ADLs, and always incontinent of bowel and bladder. Physician orders dated 7/19/2025 directed specific daily wound care for left heel and sacrococcyx deep tissue injuries, and subsequent orders on 11/11/2025, 12/17/2025, and 1/20/2026 specified detailed daily treatments for sacrococcyx stage 3 and later stage 4 pressure injuries, including cleansing solutions, topical agents, and dressings. Review of the Treatment Administration Records (TARs) from August 2025 through January 2026 showed multiple dates on which the ordered treatments were left blank, including 8/3/2025, 11/25/2025, 12/24/2025, 1/20/2026, and 1/27/2026. Interviews with the MDS nurse, RN supervisor, and other nursing staff confirmed that blank entries on the TAR indicated the treatment nurse did not sign for and therefore did not perform the ordered wound care. Staff acknowledged that if the treatment was not done, the pressure ulcer could worsen. The facility’s wound care policy required verification of a physician’s order, performance of the ordered wound care, and documentation of the type of wound care given, the date and time, the resident’s position, and the name and title of the person performing the care. The RN supervisor stated that if treatment is not done, the treatment nurse must document the reason, such as resident refusal or being too busy and endorsing the task to other staff, but such documentation was not present for the missed treatments. The deficiency also includes the facility’s failure to perform and document a complete head-to-toe skin assessment prior to the resident’s transfer to a general acute care hospital. On the transfer date, the resident’s Interact Assessment Form noted generalized weakness and decline in ADLs, and the Resident Transfer Record documented a sacrococcyx stage 3 pressure ulcer. RN 1 stated that for any transfer, a complete head-to-toe skin assessment should be done and documented on the transfer form and reported to the receiving hospital. RN 2 reported that, at the DON’s direction, she completed the Discharge Summary Report and Resident Transfer Record but only looked at the sacral area and did not perform a full body skin assessment, and therefore could not say whether the resident had rashes elsewhere. The facility’s Transfer/Discharge policy required a complete body check when possible, with findings documented, and the Prevention of Pressure Injuries policy required comprehensive skin assessments on admission, with each risk assessment, and prior to discharge. Additionally, the facility failed to obtain a physician order for the use of a wedge pillow for this resident. During observation, a wedge pillow was seen on the resident’s left side. The treatment nurse stated the wedge pillow was used to keep the sacral area off the bed to prevent worsening of the pressure ulcer. Review of the physician orders showed no order for the wedge pillow, and both RN 1 and the treatment nurse acknowledged that a physician order was required before the resident could use a wedge pillow and that the DON or RN supervisor should have obtained such an order. The facility’s policies on pressure ulcers and prevention of pressure injuries specified that the physician orders pertinent wound treatments, including pressure reduction surfaces, and that medical devices should be selected with consideration to minimizing tissue damage, reinforcing the need for an order for this device.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of employee-to-resident abuse involving Resident 2 to the State Survey Agency, Ombudsman, and local law enforcement within two hours as required by its abuse policy. Resident 2 had been admitted with dementia, Alzheimer's disease, and generalized weakness, and a subsequent H&P documented that the resident did not have capacity to understand and make decisions. An MDS later indicated Resident 2 could sometimes understand others and make self-understood and required staff supervision for toileting and showering. On the date of the incident, progress notes documented that Resident 2 became verbally and physically restless and angry before a shower, then calmed and agreed, but became physically aggressive, yelled, and spit at CNA 1 during the shower. During interviews, CNA 2 reported that while CNA 1 was showering Resident 2 and CNA 2 and a student were showering another resident in the same shower room, the resident became agitated. After the shower, Student 1 told CNA 2 that CNA 1 had slapped Resident 2 in the face. CNA 2 stated she instructed the student to report it and the student said she already had, and CNA 2 did not report the allegation directly to the Administrator, even though she acknowledged she should have. The Director of Staff Development stated CNA 1 reported only that Resident 2 became combative and spit at her, and that CNA 1 tried to block the spit with her hands. The Administrator, referencing the facility’s abuse and mistreatment policy, confirmed that all alleged and substantiated violations must be reported to the state agency and other required agencies within two hours, and stated that CNA 2 did not report the allegation on the day of the incident, resulting in the failure to meet the facility’s reporting requirements. The Administrator stated that not reporting allegations of abuse could cause Resident 2 psychological distress and potentially further abuse.
Inaccurate Skin and Medication Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with multiple serious medical conditions. The resident was admitted with diagnoses including metabolic encephalopathy, a stage 4 sacral pressure ulcer, and unspecified dementia, and was documented as having severely impaired cognitive skills and total dependence on staff for activities of daily living, with bowel and bladder incontinence. An admission reassessment documented pressure ulcers on the left heel and sacrococcyx, and the MDS indicated two unstageable pressure injuries present on admission. Subsequent skin documentation was inconsistent and inaccurate. A Skin Issues record dated 12/11/2025 indicated one stage 3 sacrococcyx pressure ulcer, while a Skin Issues record dated 1/6/2026 indicated four stage 3 pressure ulcers and one stage 4 pressure ulcer. During interviews and concurrent record review, the Treatment Nurse stated that the 1/6/2026 Skin Issues entry was not accurate and that the resident had only one stage 4 sacrococcyx pressure ulcer. The Treatment Nurse and a Registered Nurse both acknowledged that this inaccurate documentation made the medical record inaccurate and could cause confusion in care. The facility’s Charting and Documentation policy required that documentation in the medical record be objective, complete, and accurate. The facility also failed to accurately document medication administration for this resident while the resident was hospitalized. The resident’s orders included Depakote three times daily, Mirtazapine at bedtime, and Potassium chloride daily. The resident was transferred to a general acute care hospital on 1/14/2026 and returned on 1/19/2026. However, the January MAR showed that one LVN documented administration of Depakote on 1/15/2026 at noon, and another LVN documented administration of Mirtazapine, Potassium, and Depakote on 1/16/2026 at various times, despite the resident being in the hospital on those dates. The MDS nurse confirmed that check marks on the MAR indicated medications were administered and stated this documentation was incorrect because the resident was not in the facility. Nursing staff and the Registered Nurse Supervisor stated that nurses are supposed to verify that residents are in the facility, verify identity, and sign the MAR after actual medication administration, in accordance with the facility’s Charting and Documentation and Administering Medications policies, which require accurate recording of medications administered.
Failure to Timely Identify, Test, and Communicate Scabies Cases and Exposures
Penalty
Summary
The deficiency involves the facility’s failure to follow its own scabies identification and control policies and professional standards of practice for multiple residents with rashes and pruritus. One resident with a history of dermatitis, diabetes mellitus type 2, and Parkinson’s disease was admitted and later readmitted with progressively spreading rashes on the chest, bilateral upper and lower extremities, back, and abdomen. The resident’s care plan for skin integrity noted a skin rash and included interventions such as administering treatment as ordered and notifying dermatology for non-response. Over several months, skin rash reports documented complaints of itchiness on multiple dates, but there was no documented evidence that a skin scraping was performed or that a dermatologist was consulted, despite staff acknowledging that skin scraping is used to confirm scabies and that the facility had a scabies policy describing diagnostic procedures. The resident was eventually transferred to an acute care hospital for altered mental status and abnormal vital signs, with documentation noting a body rash, and a subsequent scabies examination on a later date showed a positive result for scabies. After the positive scabies result for this resident, the facility did not promptly or comprehensively identify and assess all exposed residents and staff as required by its scabies policy and the referenced Acute Communicable Disease Control (ACDC) guidelines. The Director of Staff Development (DSD) produced a new Scabies Case Contact Line List that initially included only the resident and two roommates, with no documented assessments of other exposed residents. The DSD later stated that residents who sat beside the affected resident in the dining room were only added to the line list several days after the facility became aware of the positive scabies result, and the Director of Nursing (DON) acknowledged that residents exposed in the dining room were not assessed after the positive test. Another cognitively impaired resident who attended the same dining room and activities and was identified as exposed was not assessed for scabies, and there was no documentation of assessments for other contacts beyond roommates and later-identified dining companions. The facility also failed to ensure timely and appropriate diagnostic testing and treatment sequencing for the roommate with generalized rashes. This roommate was admitted without documented skin issues, but a skin reassessment the following day showed rashes on bilateral upper and lower extremities, chest, and back. The care plan identified skin rash with interventions to administer treatment as ordered and notify dermatology of non-response. Physician orders later directed prophylactic permethrin cream application and contact isolation for possible exposure to rashes, and the medication administration record showed the permethrin was given. However, staff interviews and record review revealed that a skin scraping for this resident was ordered and performed only after the permethrin treatment had already been administered, and there was no documented evidence that a dermatologist had assessed this resident or that a skin scraping was done prior to treatment. During observation, this resident was noted to have extensive pruritic rashes in classic scabies distribution, and a CNA was seen in the room under enhanced barrier precautions without wearing PPE while touching room surfaces. Communication failures compounded these issues, as several staff members who provided direct care to the resident with confirmed scabies were not promptly informed of the positive result. A treatment nurse, a CNA, and an LVN each reported that they were not notified of the positive scabies diagnosis until two to four days after the facility became aware of it, despite having been assigned to care for the resident and having observed or managed the resident’s itching and rashes. The DSD stated she did not know if staff who cared for the resident before the positive test were notified, and the nurse practitioner reported that he was not informed of the positive scabies result. The nurse practitioner also stated that he received pushback from facility management, including the administrator, DON, and infection preventionist, when he raised concerns about ordering skin scrapings for residents with rashes, and that management expressed concern that positive scabies findings could trigger an outbreak designation and fines. The DON acknowledged that the facility had not had a dermatologist for two years, that they waited for dermatology services to determine which residents needed skin scraping, and that the facility failed to consider timely skin scraping tests and assessments for residents exposed to the confirmed scabies case. The facility’s own scabies policy and the ACDC guidelines it referenced required careful examination of roommates of infected residents, daily assessments of asymptomatic exposed residents, prompt evaluation of patients on affected units, immediate placement of suspected cases on contact precautions, preparation of line lists of symptomatic residents and their contacts, evaluation of contacts, and provision of prophylactic treatment to contacts within a short time frame. Despite these written procedures, the survey findings showed that only limited contact tracing and delayed listing of dining room contacts occurred, that not all exposed residents were assessed, that diagnostic skin scrapings were delayed or not performed for symptomatic residents, and that staff and practitioners were not promptly informed of a confirmed scabies case. Staff interviews, observations, and record reviews consistently demonstrated gaps between the written policies and the actual practices related to scabies identification, testing, communication, and contact management.
Failure to Ensure Nurse Competency in Skin Scraping Procedures
Penalty
Summary
The facility failed to ensure that three licensed nursing staff members were competent to perform skin scraping procedures, a skill necessary for diagnosing certain skin conditions. Review of the employee file for Treatment Nurse 1, hired on 11/13/2024, showed a competency skills assessment dated 1/14/2025 that did not include skin scraping. Treatment Nurse 2, hired on 2/11/2025, had a competency skills assessment dated 2/12/2025, also without any documented assessment of skin scraping. The Infection Preventionist Nurse, hired on 6/12/2024, had a competency skills assessment dated 10/13/2025, which likewise did not include skin scraping procedures. There was no documentation that any of these staff had been assessed for competency in performing skin scraping upon hire or annually. During interviews and concurrent review of employee files, the Director of Staff Development acknowledged that the competency assessments for these nurses did not include skin scraping and stated that without such assessments, the facility would not know if the nurses were performing the procedure correctly. The Director of Nursing confirmed that there were no skin scraping competency assessments completed on the licensed nurses and stated that, without these assessments, the procedure had the potential not to be done properly and could negatively affect the accuracy of results. Review of the facility’s Scabies Prevention and Control Guidelines indicated expectations for evaluation of residents and staff for scabies and access to diagnostic skills of clinicians experienced in recognizing scabies. The facility’s Competency Assessment policy stated that each employee must demonstrate competency related to skills and techniques necessary to provide care and that competency must be completed prior to assignment, which was not met for the skin scraping procedure for the identified staff.
Inaccurate and Late Documentation of Treatments and Skin Procedures
Penalty
Summary
The deficiency involves failures in maintaining complete, accurate, and professionally acceptable medical records for multiple residents. For one resident with diagnoses including dermatitis, type 2 diabetes mellitus, and Parkinson's disease, the facility admitted the resident in December 2024 and later readmitted them. The resident’s MDS dated early December 2025 showed severely impaired cognitive skills for daily decision making. Physician orders dated January 9, 2026, directed application of clotrimazole-betamethasone cream twice daily for unspecified dermatitis. A Change of Condition Interact Assessment Form dated January 16, 2026, showed the resident was transferred to a general acute care hospital on that date. However, the Treatment Administration Record (TAR) for January 2026 contained the treatment nurse’s initials on January 17, 2026, as if care had been provided while the resident was already hospitalized. The treatment nurse stated she forgot to change the chart code to hospitalized and acknowledged the documentation was not accurate. Another deficiency involved inaccurate and incomplete documentation of a second resident’s skin condition and related procedures. This resident, admitted in January 2023 with diagnoses including cerebral infarction, muscle weakness, and essential hypertension, had an MDS indicating moderately impaired cognitive skills for daily decision making. A clinical admission assessment dated December 25, 2025, documented the resident’s skin as warm, dry, with normal color and turgor and no skin issues. However, a skin reassessment dated December 26, 2025, documented rashes on bilateral lower and upper extremities, chest, and back. Physician orders dated January 26, 2026, directed a STAT skin scraping for unspecified dermatitis. The TAR for January 2026 initially showed no licensed nurse initials or time for the STAT skin scrape. A treatment nurse later stated he had only observed another treatment nurse perform the skin scraping, signed the TAR two days after the procedure, did not remember the actual time, and guessed the time for this and other residents’ procedures. The nurse who actually performed the skin scraping confirmed she did not document the procedure in the TAR and that the documentation was not timely or accurate. Similar documentation issues occurred for two additional residents with cognitive impairment and multiple medical diagnoses, including unspecified dementia, essential hypertension, age-related osteoporosis, and metabolic encephalopathy. For both residents, physician orders dated January 26, 2026, directed STAT skin scrapings for unspecified dermatitis. Their TARs for January 2026, when first printed, showed no licensed nurse initials or times for the ordered STAT skin scrapings. The observing treatment nurse later reported he had been watching another treatment nurse perform the procedures because he had not done skin scrapings before, and he signed both residents’ TARs two days after the procedures. He stated he did not remember the actual times and guessed the times, documenting the same time for both residents. The treatment nurse who performed the procedures confirmed she did not document the skin scrapings in the TARs and acknowledged the documentation was not timely or accurate. The Director of Nursing, when reviewing these records, stated that the documentation for all involved residents was not accurate and that the facility failed to follow its own charting and documentation policies, which require objective, complete, and accurate documentation of treatments, including date, time, and the name and title of the individual providing care.
Failure to Implement and Document Post-Fall Interventions and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to implement and document appropriate interventions following a resident's fall. The resident, who had diagnoses including dementia, Alzheimer's disease, muscle weakness, and difficulty walking, was identified as high risk for falls upon admission. On the day of the incident, the resident was left at the entrance of the dining room by a CNA who then clocked out. Shortly after, the resident was found on the floor, having fallen, with no staff witnessing the actual fall. Following the fall, the facility did not develop or update a care plan with interventions specific to the incident. The Fall Risk Evaluation was not updated after the event, and there was no documentation of 72-hour post-fall monitoring as required by facility policy. The Change of Condition (COC) assessment and care plan updates were not completed until several days after the fall, rather than during the same shift or the following day as expected. Additionally, there was no documented evidence that the physician or responsible representative were notified at the time of the incident. Facility policy required immediate and thorough documentation, including a complete body check, notification of the physician and family, care plan entry, and post-fall assessment, none of which were completed in a timely manner. The lack of prompt assessment, documentation, and intervention following the fall placed the resident at risk for further incidents and did not ensure adequate supervision or accident prevention.
Failure to Notify Physician and Resident Representative After Resident Fall
Penalty
Summary
The facility failed to notify the medical doctor and the resident representative after a resident experienced a fall. The resident, who had diagnoses including dementia, Alzheimer's disease, muscle weakness, and difficulty walking, was identified as high risk for falls upon admission. On the day of the incident, the resident was left in the dining room entrance by a CNA, and subsequently found on the floor by staff. Multiple staff interviews confirmed the fall occurred, but there was no immediate documentation or notification to the physician or resident representative. A review of the electronic medical record revealed that a Change in Condition (COC) assessment was not completed on the day of the fall, and was only created several days later. The Director of Nursing confirmed that the COC should have been completed during the same shift as the incident, and that the required 72-hour monitoring and care plan updates were not performed until a week after the fall. There was also no evidence that the physician or resident representative were notified at the time of the incident. Facility policies require prompt documentation and notification following a change in condition or incident, including notifying the physician and family, completing a COC assessment, and implementing monitoring. The lack of timely documentation and notification was confirmed by both record review and staff interviews, indicating a failure to follow established procedures after the resident's fall.
Failure to Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of employee-to-resident physical abuse to the State Survey Agency, the ombudsman, and local law enforcement as required by its own policy. The incident involved an activities assistant alleging that a certified nursing assistant pushed a resident in a wheelchair, which was considered a potential act of abuse. Despite the allegation, the administrator did not report the incident, citing that the resident had no injuries and that the information was considered hearsay rather than a direct report. The resident involved had significant cognitive and physical impairments, including dementia, Alzheimer's disease, muscle weakness, and a high risk for falls. The resident was dependent on staff for most activities of daily living and did not have the capacity to make decisions. On the day of the incident, the resident was found on the floor after being left in the dining room by the CNA, and there were conflicting accounts from staff regarding how the resident ended up on the floor. The administrator reviewed CCTV footage but did not preserve it, as it was automatically erased after five days. Interviews with staff revealed that the term "push" was used by the activities assistant, leading to the CNA's suspension and eventual termination. The administrator acknowledged that any allegation of abuse, including those based on staff statements or hearsay, should be reported within two hours according to facility policy. However, the administrator did not report the incident, stating it was not directly reported to her and was considered hearsay, despite recognizing that the use of the word "push" raised concerns for abuse.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Improper Disposal and Storage of Facility Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed on multiple occasions. On two separate mornings, the blue trash bin was found overfilled with its lid not fully shut, and the cardboard box bin was left open without a lid. Photographic evidence was taken to document these findings. During interviews, the Dietary Service Supervisor acknowledged that the trash bins were not closed and that the cardboard bin was overflowing and uncovered. The Director of Nursing also confirmed, upon reviewing the photographs, that the facility did not follow its own policy and procedure regarding garbage disposal, which requires bins to be covered to prevent pest attraction and disease spread. A review of the facility's policies indicated that all waste should be disposed of daily and as needed, trash bins should be covered at all times, outside garbage bins must remain closed, and cardboard boxes should be broken down and disposed of promptly. The pest control policy also requires the facility to maintain an effective pest control program and prohibits the accumulation of garbage and trash, mandating daily removal. The observed failure to keep trash bins closed and to promptly dispose of cardboard boxes was inconsistent with these established policies.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with disrobing behavior. The resident, who had diagnoses including mood disorder, major depressive disorder, and psychotic disorder, was noted to have severely impaired cognition and was dependent on staff for dressing. Despite observations and staff interviews confirming that the resident had been removing her clothes repeatedly over a two-week period, there was no care plan addressing this behavior. Nursing staff acknowledged awareness of the behavior but did not assess or create a care plan to address the resident’s dignity and respect needs related to disrobing. Additionally, the facility failed to implement a care plan for another resident prescribed carbidopa-levodopa for Parkinson Disease. The care plan indicated the need to monitor for adverse effects of the medication, such as dyskinesia, and to alert the physician if necessary. However, review of the Medication Administration Record (MAR) revealed no documentation of monitoring for adverse effects throughout the month. Both the RN and DON confirmed that monitoring should have been documented and that the lack of monitoring could result in adverse effects going unnoticed. Interviews with staff, including the DON and Pharmacy Consultant, confirmed that the facility did not follow its own policy and procedure for comprehensive, person-centered care planning. The policy required measurable objectives and timetables to meet residents’ needs, including monitoring for medication side effects and addressing behavioral issues. The failure to develop and implement appropriate care plans for both residents resulted in deficiencies related to maintaining residents’ dignity and monitoring for unnecessary medication use.
Failure to Rotate Insulin Injection Sites per Professional Standards
Penalty
Summary
Licensed nursing staff failed to provide care in accordance with professional standards by not rotating subcutaneous insulin administration sites for two residents with diabetes. For one resident with dementia and severe cognitive impairment, records showed repeated insulin injections were administered in the same areas of the abdomen and arms over several months, despite physician orders and manufacturer guidelines specifying the need to rotate sites. Interviews with the MDS Coordinator and nursing staff confirmed that injection sites were not rotated as required, and staff acknowledged this practice was inconsistent with both facility policy and professional standards. A second resident, diagnosed with metabolic encephalopathy, diabetic neuropathy, and moderate cognitive impairment, also received insulin injections at repeated sites without proper rotation. Review of medical records and interviews with nursing staff revealed multiple instances where insulin was administered in the same location, contrary to physician orders and facility policy. The Director of Nursing confirmed that staff should have checked previous injection sites in the electronic health record to ensure proper rotation, which was not done. Facility policy and manufacturer guidelines for all types of insulin administered to these residents clearly indicated the necessity of rotating injection sites to prevent complications. Despite these clear directives, the nursing staff did not adhere to the required procedures, as evidenced by documentation and staff interviews. This failure to rotate injection sites was directly observed and confirmed during the survey process.
Failure to Maintain Accident Hazard-Free Environment and Equipment Safety
Penalty
Summary
Surveyors identified that the facility failed to maintain a resident environment free from accident hazards for seven residents reviewed for accidents. Specifically, multiple residents who were assessed as high risk for falls and had orders for low beds with bilateral floor mats were found to have furniture or medical equipment placed on top of their fall mats. Observations included chairs, side tables, and bed wheels positioned on the mats, which staff and the DON acknowledged could compromise the mats' effectiveness in preventing injury. Facility policies and manufacturer instructions for the mats explicitly stated that heavy objects should not be left on the mats, as this could cause indentations and damage, reducing their protective function. In addition to the issues with fall mats, two residents were found to have bed controllers with visible, frayed, or exposed wires. Staff interviews confirmed that such conditions should have been reported to maintenance for immediate replacement, as per facility policy. The DON stated that exposed wires on bed controllers are not acceptable and should be addressed promptly to prevent potential harm. Facility policies required the maintenance department to keep all equipment in a safe and operable condition at all times. The residents involved had significant cognitive impairments, including diagnoses such as Alzheimer's disease, dementia, Parkinson's disease, and other conditions affecting their ability to make decisions or care for themselves. Many were dependent on staff for mobility and activities of daily living and had documented histories of falls or high fall risk. Despite these vulnerabilities and the presence of care plans and physician orders intended to mitigate injury risk, the facility did not ensure that environmental safety interventions were properly implemented and maintained.
Failure to Ensure Proper Pharmaceutical Services and Medication Accountability
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents and in one medication room, resulting in multiple deficiencies. For one resident with a history of cerebral infarction, dementia, and urinary tract infection, the facility received eight tablets of Augmentin as ordered by the physician. However, only seven tablets were administered and documented, with the remaining tablet unaccounted for. The Medication Disposition Log was not completed for the extra tablet, and the bubble pack was missing. The Director of Nursing acknowledged that the medication was likely discarded without proper logging, contrary to facility policy, which requires all discontinued or leftover medications to be logged and destroyed in the presence of two licensed nurses. Another resident with Parkinson's disease was prescribed carbidopa-levodopa extended-release to be administered at midnight, in addition to immediate-release doses throughout the day. The Medication Administration Record showed that the extended-release dose was consistently given at 6:30 a.m. instead of midnight, as ordered by the physician. Both the registered nurse and the Director of Nursing confirmed that this constituted a medication error, as the medication was not administered according to the prescriber's order, and the timing was not in accordance with facility policy. Additionally, in one medication room, an emergency medication kit containing controlled medications was not reconciled at every shift change as required. The kit, stored in a refrigerator, lacked an accountability log for the month reviewed. Staff interviews confirmed that all controlled medications, including those in emergency kits, should be reconciled at each shift change to ensure accountability and prevent diversion. The Director of Nursing confirmed that this process was not followed for the emergency kit in question.
Pharmacy Consultant Failed to Identify and Report Medication Monitoring Irregularities
Penalty
Summary
The Pharmacy Consultant (PC) failed to identify and report irregularities during the monthly drug regimen review (MRR) for two residents. For one resident with bipolar disorder, the PC did not ensure that there was monitoring for specific, measurable target behaviors related to the use of valproic acid, a psychotropic medication. The resident's records indicated a prescription for valproic acid to address extreme irritability affecting activities of daily living, with instructions to monitor episodes of irritability and aggression. However, the MRRs for May and June did not document any identified irregularities or report the lack of behavior monitoring to the attending physician or Director of Nursing (DON). For another resident with Parkinson Disease, the PC did not ensure monitoring for adverse effects associated with the use of carbidopa-levodopa. The care plan indicated a risk for adverse effects and the need for monitoring, but the Medication Administration Record (MAR) did not contain documentation of such monitoring. The MRRs for April, May, and June did not identify or report the absence of adverse effect monitoring to the attending physician or DON. During interviews, the PC acknowledged failing to identify and report the lack of appropriate monitoring for both residents in the monthly written reports. Facility policies and procedures required comprehensive MRRs, evaluation of medication therapy responses, and documentation and reporting of resident-specific irregularities or clinically significant risks to the DON and prescriber. The PC's failure to follow these requirements resulted in the deficiencies cited.
Failure to Monitor for Adverse Effects of Carbidopa-Levodopa
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not monitoring for adverse effects associated with carbidopa-levodopa, a medication prescribed for Parkinson’s Disease. The resident’s care plan specifically identified the risk of adverse effects, such as dyskinesia, and directed staff to monitor for these effects and alert the physician as needed. However, a review of the Medication Administration Record (MAR) for the relevant period showed no documentation of such monitoring. Interviews with both a registered nurse and the Director of Nursing confirmed that monitoring for adverse effects should have been documented on the MAR, in accordance with the care plan. Both staff members were unable to locate any evidence of monitoring for adverse effects related to carbidopa-levodopa during the specified timeframe. The lack of documentation indicated that the care plan was not implemented as intended, and the resident’s needs were not adequately addressed. The facility’s policies and procedures required monitoring for adverse consequences of medications and prompt reporting of any such events. The policies also specified that licensed nurses should review drug regimens for adequate monitoring and that adverse consequences should be minimized by following clinical guidelines. Despite these requirements, the facility did not ensure that monitoring for adverse effects of carbidopa-levodopa was performed or documented for the resident, resulting in a failure to comply with both internal policy and regulatory standards.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below five percent, as required by regulation. During an observation, a Licensed Vocational Nurse (LVN) administered four medications—famotidine, buspirone, hydrochlorothiazide, and losartan—to a resident at a time different from what was ordered by the resident’s physician. The medications were given outside the facility’s policy window of 60 minutes before or after the scheduled administration time, which was confirmed by both the LVN and the Director of Nursing (DON) during interviews. The LVN acknowledged not following the '5 rights' of medication administration, specifically the right time, and identified these as medication errors. The resident involved had a medical history including anxiety, hypertension, and gastro-esophageal reflux disease, and was prescribed the medications for these conditions. The Medication Administration Record (MAR) and physician orders specified exact times for each medication, which were not adhered to during the observed administration. The facility’s policies and procedures clearly outlined the requirement to administer medications within a one-hour window of the prescribed time, and to verify the correct time before administration. A review of facility policies further confirmed that administering medications at the wrong time constitutes a medication error. The incident resulted in four medication errors out of 26 opportunities, leading to a medication error rate of 15.38%, which exceeds the regulatory threshold. Both the LVN and DON confirmed that the medications were not administered according to physician orders or facility policy, and these actions were classified as medication errors.
Failure to Rotate Insulin Injection Sites Leads to Significant Medication Errors
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous insulin administration sites as required by physician orders, manufacturer guidelines, and professional standards. For one resident with dementia and type 2 diabetes, records showed repeated insulin injections were administered in the same anatomical areas over multiple dates, despite explicit orders and care plan interventions to rotate sites. Interviews with the MDS Coordinator and nursing staff confirmed that insulin administration sites were not rotated, and staff acknowledged this was contrary to both the physician's orders and best practice guidelines. A second resident, diagnosed with metabolic encephalopathy and diabetes with neuropathy, also received insulin injections without proper site rotation. Documentation revealed multiple instances where insulin was administered repeatedly in the same location, such as the left lower quadrant of the abdomen or the same arm, over several days. Nursing staff and the DON confirmed that the administration sites were not rotated as required, and acknowledged that staff should have checked previous administration sites in the electronic health record to avoid repetition. Review of facility policies and manufacturer guidelines for insulin administration further supported the requirement to rotate injection sites to prevent complications. The facility's own policy, as well as the prescribing information for the insulins used, specified that injection sites should be rotated within the same general area. Despite these clear directives, the facility did not ensure compliance, resulting in a significant medication error for both residents.
Failure to Label and Store Inhalation Medications per Manufacturer and Facility Policy
Penalty
Summary
Surveyors observed that the facility failed to properly label and store certain inhalation medications in accordance with manufacturer requirements and facility policy. Specifically, an open budesonide inhalation solution foil pouch for one resident was found in a medication cart without a date indicating when the pouch was opened, and three inhalation solutions remained inside the open pouch. Manufacturer guidelines require that once opened, the foil pouch should be stored at room temperature and the contents used or discarded within two weeks. The lack of labeling made it impossible to determine if the medication was still within its effective period. Additionally, an open and used budesonide and formoterol inhalation aerosol for another resident was found stored at room temperature without a date indicating when the inhaler was removed from its foil pouch. According to manufacturer instructions, this inhaler should be used or discarded within three months of opening. The absence of an open date meant staff could not verify whether the medication was still effective or had expired. Interviews with the LVN and DON confirmed that facility policy requires multi-dose products to be labeled with the date opened to track expiration, and that failure to do so prevents staff from determining the beyond-use date. Review of facility policies and manufacturer instructions further supported the requirement for proper labeling and timely use or disposal of these medications. The observed deficiencies were limited to the medications found in one medication cart and involved two residents receiving inhalation treatments for respiratory conditions.
Failure to Follow No Added Salt Diet Orders for Multiple Residents
Penalty
Summary
The facility failed to follow its own menu and nutritional guidelines by providing extra packets of salt to residents who were prescribed No Added Salt (NAS) diets. Multiple residents with medical conditions such as hypertension, heart disease, and impaired cognition were observed to have received salt packets on their meal trays, despite clear dietary orders specifying NAS diets. This was confirmed through record reviews, resident interviews, and direct observation of meal service, where kitchen staff routinely added salt and pepper packets to all trays without checking individual dietary restrictions. Residents affected included those with intact cognition who reported receiving extra salt packets, as well as residents with impaired cognition who were unable to advocate for themselves. The dietary orders for these residents specifically required NAS diets due to their medical conditions, including hypertension, heart failure, and atherosclerotic heart disease. The facility's menu and policy also indicated that NAS diets should not include salt packets, and that dietary staff are responsible for ensuring therapeutic diets are prepared and served as ordered. Interviews with the Dietary Service Supervisor and the Director of Nursing confirmed that the kitchen staff did not check tray tickets for NAS diet orders and acknowledged that this practice could negatively impact residents' medical conditions. The deficiency was identified through a combination of record review, resident council feedback, direct observation of meal trays, and staff interviews, all of which demonstrated a failure to adhere to prescribed dietary restrictions for residents requiring NAS diets.
Incomplete Medical Records and Informed Consent Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents. For one resident with depressive disorder, dementia, and psychosis, the informed consent for a psychotropic medication did not document the method used to verify that the physician discussed the risks and benefits with the resident or their representative. Both the LVN and RN confirmed that the consent form was incomplete, as the section indicating how the consent was verified was left blank. The Director of Nursing also acknowledged that the consent was not complete due to missing documentation on the verification method. For another resident with depression, dementia, and anxiety disorder, the informed consent for a mood-stabilizing medication was also incomplete. The consent form lacked the date beside the physician's signature and did not indicate how the informed consent was verified by the licensed nurse. Both the LVN and RN identified these omissions during their review, and the DON confirmed that the consent was not complete because the physician's signature was not dated and the verification method was not documented. Additionally, for a resident with cerebral infarction, dementia, and a urinary tract infection, the administration of an antibiotic (Augmentin) was not documented in the Medication Administration Record (MAR) as having been given at the prescribed time. Although the Emergency Kit Pharmacy Log showed that the medication was administered, this was not reflected in the resident's MAR. The Infection Preventionist and DON both confirmed that the lack of documentation in the MAR resulted in inaccurate medical records, as it was unclear whether the resident received the medication as ordered.
Personal Belongings Found in Clean Laundry Room Violating Infection Control Policy
Penalty
Summary
A deficiency was identified when personal belongings, including two bags, a sweater, a cellphone, and a pair of sunglasses, were observed inside the clean laundry room. These items belonged to a laundry staff member and were found hanging by the door and placed under the air-conditioning unit near a table with folded clean linens. The Housekeeping Manager confirmed that the items belonged to the staff member, and the Infection Preventionist stated that personal belongings are not permitted in the clean laundry area, as this area is designated for washed linens and clothes and must remain clean. Further interviews revealed that laundry staff are provided with lockers in the janitor room for storing personal items, and facility policy prohibits employee personal belongings from being left in the laundry area. The Director of Nursing acknowledged that the facility failed to keep the laundry area clean and free from potential infection related to the placement of personal belongings, which could result in cross contamination. Facility policies reviewed also indicated that clean linen must be protected from environmental contamination.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the administration of antibiotics to residents. The absence of such a program was identified during the survey, indicating that the facility did not take necessary actions to ensure appropriate antibiotic stewardship.
Failure to Maintain Safe Condition of Essential Equipment
Penalty
Summary
The facility failed to maintain essential electrical and patient care equipment in safe operating condition for five residents. Observations and interviews revealed that one resident's fall mat had peeling covers, compromising its integrity and the homelike environment. The fall mat was intended as an intervention for a resident with severe cognitive impairment, high fall risk, and a history of falls, as documented in the care plan and medical records. Both the LVN and DON confirmed that the mat's condition was unacceptable and did not meet facility standards for safety or environment. Additionally, four residents were found to have bed remote controls with frayed or exposed wires. These residents had varying degrees of cognitive impairment and physical dependency, with some at high risk for falls. Staff, including CNAs and the DON, acknowledged during interviews that exposed or frayed wires on bed controls posed a risk of electrocution and should have been reported immediately to the maintenance department for replacement. Observations confirmed the presence of these hazards in resident rooms, and staff admitted to not noticing or reporting the issues in a timely manner. Review of facility policies and procedures indicated that maintenance services are responsible for ensuring all equipment is safe and operable, and that staff are expected to identify and report hazards. The policies also emphasized the importance of providing a safe, clean, and homelike environment, and specifically addressed the need for electrical safety and the prevention of accident hazards. Despite these policies, the facility did not ensure that equipment such as fall mats and bed controls were maintained in safe condition, resulting in the identified deficiencies.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved. No additional information about the medical history or condition of any resident at the time of the deficiency is provided in the report.
Failure to Inform Residents of Health Status and Treatments
Penalty
Summary
Residents were not fully informed or did not fully understand their health status, care, and treatments. The deficiency was identified based on findings that residents were not provided with adequate information regarding their medical condition and the care or treatments they were receiving. This lack of communication resulted in residents not being able to make informed decisions about their care.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were administered psychotropic drugs without adequate justification or in a manner that could limit their functional abilities. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards for two residents. For one resident with a history of stage three sacral pressure ulcer, contractures, and severe cognitive impairment, there was a physician's order to apply heel protectors to both feet at all times, both in bed and in a wheelchair. Observations revealed that the resident was not wearing heel protectors, and both the CNA and LVN assigned to the resident confirmed that the heel protectors were not applied. The CNA was unaware of the order, and the LVN acknowledged responsibility for ensuring the use of pressure-relieving devices but confirmed the protectors were not in place. The RN also confirmed the order and stated that staff should have ensured the heel protectors were applied as the resident was at high risk for pressure ulcers due to fragile skin, contractures, and poor nutrition. For another resident with a stage four right gluteal pressure injury, dementia, diabetes, and severe cognitive impairment, there was a physician's order for a low air loss mattress (LALM) to be set according to the resident's current weight. The resident's weight was documented as 114 lbs, but the LALM was observed to be set at 160 lbs. The Infection Preventionist and DON both confirmed that the mattress should have been set to 120 lbs, the closest available setting to the resident's weight. The incorrect setting was not in accordance with the physician's order or the facility's care plan, which specified that the LALM should be set based on the resident's current weight to minimize the risk of skin breakdown. Facility policy and procedures required staff to review care plans, identify risk factors, and implement appropriate interventions, including the use of pressure-relieving devices and support surfaces. The operations manual for the LALM also specified that the mattress should be adjusted according to the patient's weight. Despite these guidelines, staff failed to ensure that the prescribed interventions were implemented for both residents, as evidenced by the lack of heel protectors and the incorrect LALM setting.
Failure to Ensure Required Physician and Psychiatrist Visits
Penalty
Summary
The facility failed to ensure that a resident received required face-to-face visits from both the attending physician (AP) and the psychiatrist (Psych MD) as mandated. Specifically, the AP did not make an initial face-to-face visit within 30 days of admission during the first 90 days, and the Psych MD did not conduct a required visit as per physician orders. Instead, nurse practitioners (NPs) conducted all visits for both the AP and the Psych MD, with no documentation of direct visits from the physicians themselves. Review of the resident's medical record confirmed the absence of progress notes or history and physical documentation from either the AP or the Psych MD. The resident involved had diagnoses including cerebral ischemia, unspecified dementia, and insomnia, with documentation indicating severely impaired cognitive skills and lack of capacity to make decisions. Despite orders for psychiatric consultation and follow-up, only NPs performed these visits. Interviews with nursing staff and the DON confirmed that the AP and Psych MD did not see the resident, and the facility's policy requiring physician visits was not followed. The DON acknowledged the failure to ensure required physician visits occurred.
Failure to Ensure Resident Access to Survey Results
Penalty
Summary
The facility failed to ensure that two residents who attended a Resident Council Meeting were aware of the availability and location of the facility's latest survey results. During interviews, both residents stated they did not know where to find the survey results or how the facility addressed previously identified deficiencies. The residents expressed a desire to be informed about the facility's most recent survey inspection results and the corrective actions taken. Observation and interviews with staff revealed that the survey result binder was stored under a cabinet in the dining room, with a label too small for residents to read. Although the facility maintained two survey binders—one in the front lobby and one in the dining room—residents were only informed that they could ask staff to access the binder. Staff acknowledged that the binder should be easily accessible to residents without staff assistance. Review of facility policies confirmed that survey results should be maintained in an area frequented by residents and be readily accessible for examination.
Resident Room Size Below Regulatory Standards
Penalty
Summary
The facility failed to meet the required room size of at least 80 square feet per resident in multiple resident bedrooms, affecting 19 out of 34 rooms. Observations, interviews, and record reviews confirmed that these rooms, each housing three residents, ranged from 195 to 238 square feet, which is below the minimum standard of 240 square feet for three-bed rooms. The facility had submitted a variance request acknowledging the deficiency, and documentation indicated that the rooms did not meet federal and state requirements for space per resident. During the survey, staff and residents reported no issues with space, and observations showed that residents and staff could move freely within the rooms, with sufficient space for beds, dressers, and care equipment. The administrator confirmed the deficiency and stated that no complaints had been received from residents regarding room size. The facility's policy also requires bedrooms to meet the 80 square feet per resident standard, which was not met in the identified rooms.
Failure to Maintain Resident Dignity During Staff Interaction
Penalty
Summary
A deficiency occurred when a staff member failed to respect a resident's right to dignity during a lunch service. The resident, who had diagnoses including unspecified dementia, schizoaffective disorder bipolar type, and other persistent mood disorders, was noted to be severely impaired in thought process and judgment. During the incident, the resident became aggressive and threw a spoon at a certified nursing assistant (CNA). In response, the CNA threw the spoon back toward the resident and raised her voice at the resident. Another CNA present confirmed witnessing the staff member raise her voice and return the spoon, stating that these actions did not provide a dignified existence for the resident. The facility's policy on dignity, last revised in 2021, requires that residents be treated with dignity and respect at all times, with special sensitivity toward cognitively impaired residents. The policy specifically instructs staff to address the underlying causes of resident behavior and to avoid challenging or contradicting residents' beliefs or statements. The actions of the CNA in this incident were inconsistent with these policy requirements, resulting in a failure to honor the resident's rights and dignity.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for two residents, leading to a potential delay in care. Resident 2, admitted with Alzheimer's Disease, hypertension, and cognitive communication deficit, was observed with the call light on the floor by the right side of the bed, out of reach. The resident's care plan, which was last revised in March 2025, indicated that the call light should be within reach to attend to needs promptly. Similarly, Resident 3, who has chronic obstructive pulmonary disease, muscle weakness, and Alzheimer's Disease, was observed with the call light tangled with another resident's call light and on the floor, making it inaccessible. The care plan for Resident 3 also required the call light to be within reach. During observations, staff members, including a Certified Nursing Assistant (CNA) and a Restorative Nursing Assistant (RNA), failed to notice or rectify the situation, leaving the call lights out of reach. The Director of Nursing (DON) acknowledged the failure to ensure the call lights were accessible, which is crucial for residents to call for assistance. The facility's policy, reviewed in January 2025, mandates that residents have a means to call staff for assistance from their bed, toileting, or bathing facilities, and the floor, emphasizing the importance of having the call light within reach.
Failure to Notify Physician of Residents' Skin Condition Changes
Penalty
Summary
The facility failed to notify the physician when two residents experienced changes in their skin condition, specifically rashes and itchiness. Resident 1, who was admitted with conditions including hypertension and dysphagia, was observed with raised, open, and red skin rashes while moaning and itching her arms. Despite these observations, the nursing notes did not document any notification to the physician or family. The MDS coordinator confirmed the absence of documentation indicating physician notification. Resident 2, admitted with Alzheimer's disease and unspecified dermatitis, was observed scratching her neck, chest, and back, reporting that the itchiness had persisted for weeks and was severe enough to disrupt her sleep. The LVN admitted to not notifying the physician about the changes in condition for both residents. The facility's policy requires prompt physician notification for any change in a resident's condition, which was not adhered to in these cases. The physician was unaware of these changes and planned to visit the facility to assess the situation.
Failure to Notify Physician of Residents' Skin Conditions
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in managing their skin conditions. Resident 1, who was admitted with diagnoses including hypertension, angina pectoris, and dysphagia, was observed with a skin rash and itchiness on both upper and lower extremities. Despite the presence of raised, open, and red rashes, the Licensed Vocational Nurse (LVN) did not inform the Medical Doctor (MD) of the change in condition, as required by the facility's policy. The nursing notes also failed to document any notification to the physician or family, placing Resident 1 at risk for further skin irritation and delayed care. Similarly, Resident 2, admitted with Alzheimer's disease, metabolic encephalopathy, and unspecified dermatitis, experienced severe skin itchiness that disrupted her sleep. Despite her complaints and the application of cream by the staff, the itchiness persisted, and there was no documented evidence of physician notification. The Registered Nurse (RN) confirmed the lack of documentation, and the Director of Nursing (DON) acknowledged the policy to report changes in condition but could not explain the oversight. The MD was unaware of the residents' conditions and planned to visit the facility to assess the situation.
Inadequate Disinfection During IGAS Outbreak
Penalty
Summary
The facility failed to implement and maintain an effective infection control program during an outbreak of invasive group A streptococcus (IGAS). The deficiency was identified through interviews and record reviews, which revealed that high touch areas at Nursing Station 1 and Nursing Station 2 were not routinely disinfected as required. The facility's disinfection logs for high touch areas indicated that licensed nurses (LNs) were responsible for disinfecting these areas during specific shifts when housekeeping staff were not present. However, the logs showed multiple instances where LNs did not document their disinfection activities, suggesting that the disinfection may not have been performed. Interviews with the Director of Staff Development (DSD) and the Infection Preventionist (IP) confirmed the presence of an IGAS outbreak in the facility and highlighted the importance of regular disinfection to prevent the spread of the infection. The IP reviewed the disinfection logs and noted several dates where LNs failed to initial the logs, indicating a lack of compliance with the disinfection protocol. The IP emphasized that the logs were created to ensure disinfection was carried out during the outbreak, and the absence of documentation implied that the disinfection was not done. The Director of Nursing (DON) acknowledged awareness of the incomplete disinfection logs and stressed the importance of LNs completing them to confirm that disinfection was performed, especially during hours when housekeeping staff were unavailable. The facility's policies on infection control and communicable diseases, as well as cleaning and disinfection procedures, were reviewed, indicating that the facility had established protocols for maintaining a safe and sanitary environment. However, the failure to adhere to these protocols during the IGAS outbreak resulted in a deficiency in the infection control program.
Delay in STAT X-ray for Resident After Fall
Penalty
Summary
The facility failed to ensure a STAT X-ray was implemented in a timely manner for a resident who had a fall and was suspected to have a fracture. The resident, who had Alzheimer's Disease and severe cognitive impairment, was admitted with a displaced left proximal humerus fracture. After a fall, a STAT X-ray was ordered to assess the resident's left humerus, but it was not conducted within the required four to six-hour window. The delay in obtaining the X-ray results led to a delay in necessary medical care for the resident. Interviews with the Director of Nursing and nursing staff revealed that the STAT X-ray order was not followed promptly due to staff being busy and not following up with the radiology provider. The facility's policy and contract with the radiology provider indicated that STAT X-rays should be completed within four hours, but this was not adhered to. As a result, the resident was eventually transferred to a general acute hospital for further evaluation, where the X-ray confirmed an acute displaced and angulated midshaft humeral fracture.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility was found to have multiple deficiencies in its food storage and preparation practices, which were observed during a survey. The walk-in refrigerator had shelves that were chipped and cracked, which the Dietary Supervisor acknowledged could harbor bacteria and lead to cross-contamination. Additionally, the freezers had dried up pink liquid, dust buildup, and tape debris on the bottom shelves, which were not cleaned as per the facility's policy. These conditions were noted to potentially attract germs and cause foodborne illnesses among the residents. In the dry storage area, a dented can was found stored with non-dented cans, which the Dietary Supervisor stated could lead to botulism if consumed. The knife container and a scoop with a sticky residue were also found to be unclean, posing a risk of cross-contamination. Furthermore, the storage of scoops was disorganized, with handles facing different directions, which was not in line with sanitary practices. The clean storage area for pots and pans was found to have dust, crumbs, and food residues, and the mixer had dirt and food buildup, indicating a lack of proper cleaning after use. Food carts used for lunch service had dried milk spills and tape residues, which were not cleaned after each meal, as required by the facility's cleaning schedule. Additionally, a resident's food from home in the refrigerator was not labeled with a name or received date, which the Director of Nursing admitted was a mistake. This lack of labeling could lead to incorrect diet administration and potential allergic reactions. These deficiencies in food storage and preparation practices posed a risk of harmful bacteria growth and cross-contamination, potentially leading to foodborne illnesses among the residents.
Deficient Policy on Storage of Outside Food
Penalty
Summary
The facility failed to have a comprehensive policy regarding the use and storage of food brought to residents by family and other visitors, which could ensure safe and sanitary storage, handling, and consumption. The existing policy discouraged bringing outside food due to concerns with food safety and infection control but allowed it as a resident's right, especially if the resident was eating poorly. The policy did not clearly outline the facility's responsibility for storing food beyond one mealtime, nor did it provide specific guidelines for safe food storage. The Registered Dietitian (RD) and Director of Nursing (DON) acknowledged that the policy was general and lacked guidance for food storage, which could lead to emotional changes in behavior and potential weight loss among residents. During interviews, the RD stated that food brought from outside was labeled, dated, and stored in the resident's refrigerator, with a practice of discarding any food after 72 hours. However, the policy did not explicitly mention these storage guidelines, leading to potential non-compliance by residents if unexpired food was discarded. The DON also noted that the policy needed revision as it was too general and did not provide adequate guidance for food storage. The lack of a clear policy had the potential to cause decreased food intake, unintentional weight loss, frustrations, and psychosocial harm to all 78 residents in the facility.
Improper Garbage Disposal and Cleanliness in Trash Area
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed in the trash area outside the facility. The dumpster area was found to be littered with soiled plastic utensils, trash, and liquid drippings, which were not adequately cleaned. During an observation and interview with the Dietary Supervisor, it was confirmed that the trash surroundings were not clean. The Maintenance Supervisor, responsible for cleaning the area, admitted to using a blower to clear leaves but did not use water pressure for cleaning. He acknowledged the importance of maintaining cleanliness to prevent infection spread but was unsure of the current state of cleanliness. The Housekeeping Supervisor also confirmed that the trash area had trash and liquid drippings, despite having cleaned the surroundings earlier that morning. The facility's policies and procedures on waste control and disposal, dated January 2024, require that outside garbage bins be kept closed and the surrounding area kept clean. Additionally, the Food Code 2017 mandates that outside receptacles for refuse be designed with tight-fitting lids and kept covered to prevent contamination. The failure to adhere to these guidelines posed a potential risk of attracting pests and spreading infection to all 78 residents of the facility.
Sanitation Deficiency in Food Services Due to Fly Presence
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of a fly in the kitchen. During an observation and interview with the Registered Dietitian (RD) and the Dietary Supervisor (DS), a fly was seen landing on a can opener and later on a baked good in the trayline area. The DS acknowledged that the fly could have entered from the breakroom or office when staff opened the door and expressed concern about the potential for germs to be transmitted to food, which could lead to residents getting sick. The facility's Pest Control Policy, dated earlier in the year, indicated that the facility should maintain an effective pest control program to keep the building free of insects and rodents.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were available and within reach for five residents, leading to a deficiency in accommodating resident needs and preferences. Resident 25, who was admitted with severe cognitive impairments and was dependent on staff for daily activities, did not have a call light available for use. This was confirmed during an observation by a Certified Nursing Assistant (CNA), who acknowledged the importance of having a call light to prevent accidents. The Director of Nursing (DON) also stated that the absence of a call light could delay care, and the facility's policy required call lights to be within reach of all residents. Resident 52, who had a history of falling and cognitive impairments, was observed with a call light that was not within reach while lying in bed. A CNA had to move the call light to make it accessible, emphasizing the necessity of having it within reach. Similarly, Resident 31, who required assistance for mobility and had a history of falls, was found in a wheelchair with the call light clipped to the bed, out of reach. The CNA and a Registered Nurse (RN) both highlighted the importance of having the call light accessible to prevent residents from attempting to move unassisted, which could lead to falls and injuries. Residents 57 and 35 also experienced similar issues with call lights being out of reach. Resident 57, who was dependent on staff for daily activities, was observed in a wheelchair with the call light clipped to the bed, inaccessible. Resident 35, with severe cognitive impairments and a high risk for falls, had the call light placed on top of the bed, out of reach while in a wheelchair. The DON reiterated that the facility's policy required call lights to be within reach to ensure prompt assistance and prevent accidents. The consistent failure to adhere to this policy across multiple residents highlights a significant deficiency in the facility's accommodation of resident needs.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to reflect documented evidence of discussions regarding advance directives (ADs) and to maintain a current copy of the AD in the clinical records for three of four sampled residents. This deficiency was identified during interviews and record reviews for Residents 21, 52, and 57. The absence of ADs in the residents' charts violated their rights to have their healthcare wishes documented and respected, potentially leading to conflicts with their healthcare preferences. Resident 21 was admitted with diagnoses including Alzheimer's disease, unspecified dementia, and schizoaffective disorder. The resident's Minimum Data Set (MDS) indicated limited ability to understand and communicate, requiring substantial assistance for daily activities. Despite an Advance Directive Acknowledgment form indicating the execution of an AD, the document was missing from the resident's chart. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Director of Staff Development (DSD), and the Director of Nursing (DON), confirmed the absence of the AD in the chart, contrary to facility policy. Similarly, Resident 52, with diagnoses of psychosis and unspecified dementia, had an executed AD according to the History and Physical (H&P) records, but it was not present in the chart. Resident 57, diagnosed with Alzheimer's disease and unspecified dementia, also lacked a completed AD Acknowledgment form, with no documentation indicating the resident's representative was informed of their rights. Interviews with the DSD and DON highlighted the failure to follow facility policy, which mandates the documentation and accessibility of ADs in residents' medical records to ensure their healthcare wishes are known and respected.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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