Arbor Glen Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendora, California.
- Location
- 1033 E. Arrow Highway, Glendora, California 91740
- CMS Provider Number
- 056360
- Inspections on file
- 55
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Arbor Glen Care Center during CMS and state inspections, most recent first.
Failure to maintain resident privacy during personal care: two residents were observed with drapes only partially drawn while CNAs provided hygiene and incontinence care. One resident was exposed from the waist down during cleanup, and another resident’s back, buttocks, and scrotal area were exposed during peri care in a double occupancy room. The DON and CNA acknowledged the curtains should have been fully closed for privacy and dignity.
A resident who was hard of hearing had an ordered ear lavage that was not completed, a second resident’s fall risk evaluation was not done after an unwitnessed fall despite a care plan identifying fall risk, and a third resident with a POLST/DNR order received CPR after being found without a pulse or respirations. The DON and other staff confirmed the missed ear treatment, the missing post-fall evaluation, and that CPR should not have been performed when the resident’s DNR order was in place.
Unsafe food storage and labeling practices were observed in Kitchen 1. Expired Caesar dressing was found in a refrigerator, an open bin of ready-to-eat corn flakes with raisins was unlabeled and undated, and two uncovered pans of facility-baked yellow cake were stored on top of a bin of beans while cooling. The DS stated the dressing should not have been accepted, the cereal should have been labeled with an open and use-by date, and the cakes were left uncovered because they were cooling; the RD stated the cakes could have been stored in a cart instead of on the shelving rack.
A resident with breast cancer and brain cancer had physician orders for PT and OT evals, but the rehab record contained no documentation that either eval was completed. The DOR confirmed the missing documentation meant the evals were not done, and the facility policy required therapy services to begin with an initial clinician eval initiated within 72 hours of the order.
An unlabeled shampoo and body wash was found in a shared restroom used by four residents on EBP. CNA and IP interviews confirmed personal care items should be labeled with a resident's name and stored in the resident's designated area, but this item was left on the sink in the common restroom. The affected residents had diagnoses including CVA, hemiplegia/hemiparesis, PVD, and anemia, with varying cognitive and functional levels.
Failure to Notify Ombudsman of Resident Transfer: A resident with COPD and generalized weakness was transferred to an acute hospital for possible stroke or sepsis, but the facility did not notify the Ombudsman of the transfer. The SSD stated the Ombudsman needed to be notified because the resident was a facility resident, and the facility’s discharge planning policy did not include a process for ombudsman notification.
Inaccurate Hearing Assessment on MDS: A resident with intact cognition and diagnoses including atrial fibrillation, dysphagia, and generalized muscle weakness was assessed on the MDS as having minimal hearing difficulty, but during survey observation the resident stated they had trouble hearing and needed staff to speak louder and remove a mask to hear. The MDS Coordinator confirmed the hearing status should have reflected moderate difficulty, and the DON stated accurate assessment was important for appropriate care.
Failure to develop a person-centered care plan for a resident’s hearing difficulty. The resident had intact cognition, could make decisions, and the MDS indicated minimal hearing difficulty, but the resident stated they had trouble hearing before admission and asked staff to speak louder and lower their mask. The MDS Coordinator confirmed there was no care plan addressing the hearing issue, despite facility policy requiring a comprehensive care plan with measurable objectives and timeframes.
An LVN prepared seven oral meds for a resident’s scheduled med pass and brought them to the room, but only stated that the 9 AM meds would be given and did not explain the types of meds being administered. The resident had diagnoses including DM2 and parkinsonism, and the H&P indicated the resident had capacity to understand and make decisions. The facility’s Med Pass policy stated to explain to residents the type of medication being administered, and the DON stated this was standard nursing practice and a patient right.
A resident who spoke Mandarin and did not speak English was not provided a communication tool or interpreter support to help staff communicate the resident’s needs. The resident had diagnoses including traumatic subdural hemorrhage and impaired gait/mobility, and was documented as alert and oriented to person only. During care, an LVN used gestures instead of a communication board, and family confirmed the resident communicated in Mandarin. The LVN and DON both acknowledged that communication tools were important for effective communication and meeting resident needs.
Failure to Provide Needed Grooming and Hygiene Assistance: A resident with heart failure, HTN, gait abnormalities, and impaired cognition was identified as needing help with ADLs and personal hygiene, including shaving and hand washing. During observation, the resident had unshaven facial hair, long fingernails with dark debris underneath, and scratch marks on the arms and forehead. The resident said requests to be shaved were not always done and that no one cut the nails; an LVN confirmed the nails were not clean and that the beard and nails needed attention. The DON stated long fingernails were not acceptable and were a sign of poor hygiene.
A resident with an unstageable sacral PI and mild PI risk had a low air loss mattress ordered for wound healing, but staff observed the mattress set on static mode instead of intermittent pressure. RN and DON stated the mattress needed to be on alternating pressure to promote healing, while the manufacturer’s manual described static mode as non-alternating and always inflated.
Failure to supervise two residents while smoking in the patio smoking area. One resident had diagnoses including muscle weakness and schizoaffective bipolar disorder, and the other had acute pancreatitis, muscle weakness, difficulty walking, and nicotine dependence. Both residents' care plans identified smoking-related risk, but neither specified supervision while smoking. Surveyors observed one resident smoking alone and later observed both residents smoking unsupervised; the HRM said residents may sometimes be left alone if they are awake, alert, and oriented, while the IPN and DON stated the smoking policy required staff to be present.
Call lights were not within reach for two residents. One resident with dementia, metabolic encephalopathy, and an impaired upper extremity had a touchpad call light placed behind the resident on the right side, while an RN stated it should have been placed near the resident’s left hand. Another resident with hemiplegia/hemiparesis and total dependence for transfers and toilet use had a call light placed near the right shoulder but stated it could not be reached because the resident could not use the right arm or cross over with the left arm. The DON stated call lights should be within reach, and the facility P&P required placing the call device within the resident’s reach before leaving the room.
A resident with muscle weakness, a left femur fracture, moderately impaired cognition, and a Stage 4 pressure ulcer had a care plan and facility policy requiring assistance with turning and repositioning at least every two hours and as needed. Observations showed the resident remained in essentially the same side-lying position with a pillow under one shoulder and down to the waist over several hours. A CNA reported changing the resident’s brief but not repositioning the resident due to the resident’s refusal and did not notify a nurse of this refusal, despite expectations that refusals be reported so licensed staff could follow up. This resulted in a failure to provide pressure ulcer care as planned and required.
A resident with a Stage 4 pressure ulcer, muscle weakness, and a prior femur fracture had a PRN order for hydrocodone-acetaminophen for severe pain but did not receive pain medication before wound care and a subsequent bed bath. During the observed care, the resident repeatedly reported pain at level 7, moaned with repositioning, and cried out in pain multiple times, yet the treatment nurse and CNAs continued the procedures without premedicating or allowing time for analgesia to take effect. The resident later stated they had experienced prolonged pain, and interviews with the TN and DON, along with the facility’s pain management policy, confirmed that pain should have been anticipated and managed prior to these treatments.
Staff failed to follow Enhanced Barrier Precautions when a CNA provided a bed bath to a resident with MDRO and an indwelling urinary catheter, then immediately proceeded to bathe another resident with infection-related cardiac device complications and endocarditis without changing the protective gown or performing hand hygiene. Although facility policy required gown and glove use for high-contact care under EBP and mandated changing gowns and gloves and performing hand hygiene after each resident encounter, the CNA only changed gloves, believing the first resident was not on precautions and that the gown was merely preventive. The IP nurse confirmed the resident was on EBP for a history of MDRO in the urine and that EBP was intended to prevent MDRO transmission.
A resident with DM and a markedly elevated Hgb A1C was admitted on long‑term insulin therapy and had intact cognition and decision‑making capacity. Review of physician orders and MARs showed that scheduled Humalog and Lantus orders expired, and for eight days there were no active orders or administration of any oral or injectable DM medications. Progress notes documented that the resident was not on diabetic medications after hospital insulin orders ended and that the physician could not be reached, while the resident and a home health agency administrator requested delaying discharge until an insulin regimen was established. In interviews, nursing leadership and an RN confirmed the lapse in insulin therapy and acknowledged that nurses were responsible under facility policy and job descriptions to monitor the resident’s condition, recognize abnormal findings, and consult with the physician regarding continuation of insulin management.
Two residents with significant medical needs experienced prolonged waits—ranging from 30 minutes to 2 hours—for staff to respond to call lights, including requests for toileting assistance. Both residents, who required varying levels of assistance with activities of daily living, reported these delays during interviews. The DON confirmed that such wait times are not acceptable, and facility policies require prompt response and respectful treatment.
Two residents expressed concerns about long wait times for staff assistance during shift changes at resident council meetings. Although the AD reported these complaints to the DON, no Plan of Action form was created as required by facility policy, resulting in the concerns not being formally addressed.
Facility staff did not document a resident's visit to a urologist in the medical record, despite facility policy requiring physician visits to be recorded. The omission was confirmed by the DON and resulted in incomplete medical documentation for a resident with multiple diagnoses and care needs.
A resident with significant care needs and frequent incontinence did not receive timely assistance after activating the call light for help with a brief change. Staff were observed walking past the room without responding, and the resident reported repeated delays of 30 minutes or more. CNAs indicated that licensed nurses did not help with call lights, despite facility policy and leadership stating that all staff are responsible for prompt responses.
A resident with significant medical needs and frequent incontinence did not receive timely assistance with ADLs, specifically incontinence care, after activating the call light. Staff were observed walking past the room without responding, and interviews revealed that licensed nurses often did not help answer call lights, leaving the responsibility to CNAs. Facility policy and care plans required prompt assistance, but this was not provided, resulting in the resident waiting extended periods for care.
A resident with a gastrostomy tube for enteral feeding received care from CNAs who operated the tube feeding machine, despite facility policy and staff statements that only licensed nurses are permitted to do so. CNAs reported routinely putting tube feeding machines on hold and resuming them after care, even though they were not trained or authorized for this task. Facility policies, job descriptions, and competency checklists confirmed that tube feeding management is not within the CNA scope of practice.
A resident dependent on tube feeding received care from a CNA who operated the enteral feeding pump, contrary to facility policy and staff training requirements. Staff interviews revealed inconsistent practices and understanding about who is authorized to operate tube feeding machines, with only licensed nurses permitted to do so according to facility policy and competency checklists.
A resident with a gastrostomy tube, dependent on staff for all care, did not receive proper Enhanced Barrier Precautions (EBP) when a CNA provided care without wearing an isolation gown, despite clear signage and facility policy requiring gown and glove use for residents with indwelling devices. Staff interviews confirmed knowledge of EBP requirements, and the deficiency was observed during high-contact care activities.
The facility failed to prevent and manage pressure ulcers for three residents. One resident with a Stage 4 ulcer was not repositioned as required, leading to potential worsening of the condition. Another high-risk resident was not turned regularly, resulting in new pressure injuries. A third resident's low air loss mattress pump was found off, contrary to care plans, risking further skin breakdown.
A facility failed to implement its Infection Prevention and Control Program, leading to potential cross-contamination. Unlabeled personal toiletries were found in a shared restroom, and staff did not adhere to PPE protocols for residents on contact isolation. CNAs did not change gowns and gloves between residents, and a CNA entered a room with residents on contact precautions without PPE. The Infection Preventionist Nurse emphasized the importance of proper PPE use and labeling to prevent infection spread.
The facility failed to implement its antibiotic stewardship program for three residents, leading to unnecessary antibiotic administration. A resident was given Ertapenem Sodium without completing the necessary infection surveillance form. Another resident received Ampicillin Sodium without confirming the criteria for its use, and the IPN did not follow up with the physician. A third resident was administered Zosyn for pneumonia without completing the required documentation. These actions were contrary to the facility's policy on antibiotic stewardship.
A resident's call light was found on the floor and out of reach, potentially delaying necessary care. The resident, with moderate cognitive impairment and requiring substantial assistance, was unable to access the call light. Staff interviews confirmed the importance of accessible call lights for safety, aligning with facility policy.
A facility failed to provide adequate staffing, resulting in delayed incontinence care and loss of dignity for two residents. One resident, with heart failure and diabetes, experienced significant delays in changing soiled briefs, impacting their therapy schedule. Another resident with Alzheimer's disease was observed seeking help in the hallway but was not immediately assisted by busy CNAs. The facility's staffing policy was not followed, leading to these deficiencies.
A resident with Alzheimer's and severe cognitive impairment was not treated with dignity when a CNA dismissed their request for help, stating they were busy. Other CNAs and the DON acknowledged the inappropriate response, emphasizing the need for compassion and respect for all residents.
A resident with Parkinson's disease and hand rigidity was provided with an unsuitable push call light system, despite being dependent on others for daily activities and mobility. An LVN and the DON acknowledged the need for a more appropriate system, such as a tap or mechanical pad, to ensure the resident could effectively alert staff for assistance. The facility's policy on accommodating residents' needs was not followed in this case.
A resident was admitted to the facility without a required PASARR screening, despite having multiple mental disorder diagnoses. The facility's policies mandate this screening to ensure appropriate care, but it was not conducted, leaving the facility without crucial information on the resident's mental health needs.
A facility failed to provide documented activities for a resident, potentially affecting their psychosocial well-being. Observations showed the resident lying in bed without engagement, and interviews revealed a lack of documentation for activities provided. The resident's activity preferences were not assessed, leaving staff without guidance on meaningful activities.
A resident with a history of constipation was not managed according to physician's orders, leading to multiple bowel movements and eventual hospital transfer. The resident refused Milk of Magnesia, and the LVN administered a Dulcolax suppository without consulting the physician, contrary to orders. The DON confirmed the failure to follow protocols, resulting in the resident's condition worsening.
A resident receiving continuous oxygen therapy at 2 LPM via nasal cannula did not have the required oxygen warning signage posted in their room, as per facility policy. This oversight was confirmed during an observation and interview with an LVN, who acknowledged the need for signage to prevent fire risks. The facility's policy mandates NO SMOKING/OXYGEN IN USE signs to ensure safety.
The facility failed to maintain adequate quaternary sanitizing solution levels in one of the kitchen's sanitation buckets, compromising its effectiveness. A test strip showed a concentration of 100 ppm, below the required 200-400 ppm range. The issue was linked to too many washcloths in the bucket, reducing the solution's potency. This deficiency was confirmed through staff interviews and record reviews.
The facility failed to have the Director of Nursing (DON) present at a required QAPI quarterly meeting. The absence was confirmed through a review of the QAPI Sign in Sheet and an interview with the Administrator, who acknowledged the necessity of the DON's attendance for planning and monitoring nursing services. The facility's QAPI Plan identified the DON as the clinical care sub-committee leader, underscoring the importance of their role.
A facility was found to have exceeded the maximum resident occupancy in a room, with six residents accommodated in a space meant for no more than four. This was confirmed through interviews with a Treatment Nurse and the Administrator, who admitted to adding a sixth bed and resident without a policy in place to guide room occupancy limits.
A resident with a history of falls was inaccurately assessed, leading to a change in their fall risk category from high to medium. The LVN admitted to the documentation error, which contradicted the facility's policy for accurate assessments to guide care plans.
The facility failed to update the care plans for two residents after significant health events. One resident experienced falls on two occasions, and the care plan was not revised to address the increased fall risk. Another resident developed a pressure injury and refused repositioning, but the care plan remained generic and did not include specific interventions. The facility's policies require care plan updates to address such changes in condition, but these were not followed, potentially impacting the residents' well-being.
Two residents in an LTC facility experienced falls due to inadequate supervision and failure to maintain a safe environment. One resident's bed was not kept in the lowest position as required, increasing fall risk. Another resident, at high risk for falls, fell after attempting to get out of bed without assistance. Despite being informed, an LVN did not intervene, citing it was not her responsibility, highlighting a lack of teamwork and communication among staff.
A facility failed to follow its policy for controlled medication administration for five residents. An LVN did not sign the controlled medication count sheets or the MAR after administering medications, risking medication errors and accountability issues. The DON highlighted the importance of accurate documentation to prevent medication diversion and ensure resident safety.
A resident with significant medical needs, including a gastrostomy tube, was observed with an abdominal binder, but the facility failed to implement a care plan for its use despite a physician's order. Staff interviews revealed a lack of awareness and adherence to the facility's policy requiring comprehensive care planning, leading to potential inconsistent care.
The facility failed to ensure proper hand hygiene practices, as observed with an LVN and a CNA who did not wash hands or use sanitizer after resident contact and before handling meal trays. This non-compliance with the facility's hand hygiene policy was confirmed by staff interviews and the Interim Director of Nursing.
A facility failed to provide proper care for a resident's PICC site, leading to potential infection risks. The resident, with cellulitis and diabetes, had orders for regular monitoring and IV antibiotics. However, the PICC site was not cleaned or the dressing changed as required. Observations showed dried blood and a loose dressing, and interviews revealed that nurses did not assess the site during medication administration. The facility's policy emphasized the need for regular dressing changes to prevent infections.
A resident with a high fall risk was not provided with bilateral floor mats as per their care plan and physician's orders, leading to a fall and skin tear. Staff interviews revealed a lack of communication and adherence to fall prevention protocols, with no fall precaution indicators present. The facility's policy on implementing physician orders was not followed, potentially placing the resident at risk for further falls.
A resident with a history of multiple sclerosis and cerebral palsy developed a breast lump that was not promptly addressed by the facility. Despite the resident's requests, staff failed to notify the primary care provider or schedule a mammogram, leading to a delayed cancer diagnosis. The resident experienced severe pain and was eventually transferred to a hospital, where a biopsy confirmed breast cancer. Interviews revealed lapses in communication and adherence to care policies.
CNAs failed to respect a resident's request on how to be turned in bed, leading to a fracture in her right arm. Despite the resident's intact cognition and existing medical conditions, including a broken left arm and severe osteoporosis, the CNAs insisted on turning her their way, resulting in severe pain and a displaced fracture. The incident highlighted a disregard for the resident's dignity and rights, as acknowledged by the DON.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure dignity and privacy for two sampled residents during personal care. Resident 104, newly admitted with generalized muscle weakness and essential hypertension, was observed on 3/24/2026 lying in bed between two roommates while CNA 5 prepared to clean the resident. Resident 104's drapes were only partially drawn, and CNA 5 removed the bed sheet, exposing the resident from the waist down and making the diaper visible to others. CNA 5 stated the drapes should have been closed all the way around the bed before cleaning began, and the DON stated that drapes should be closed all the way around a resident's bed for privacy when cleaning up a resident. Resident 6, who had diagnoses including type 2 DM and obesity, was admitted and readmitted to the facility, had intact cognitive skills, and was dependent for ADLs with frequent urinary and bowel incontinence. The care plan directed staff to promote dignity by ensuring privacy. On 3/27/2026, Resident 6 was observed awake and alert in a double occupancy room, positioned on the left side while CNA 7 and CNA 8 provided care for bowel incontinence. The drapes were only partially drawn, and Resident 6's back, buttocks, and scrotal area with external hemorrhoids were exposed. CNA 7 stated the drapes should have been completely closed for dignity and privacy and to prevent exposure if the roommate walked in.
Failure to Follow Physician Orders for Ear Care, Fall Assessment, and DNR Status
Penalty
Summary
The facility failed to follow a physician order for ear lavage for a resident who was hard of hearing. The resident’s record showed an order for a one-time ear lavage, but the MAR for that date was left blank and the treatment was not completed. During interview, the resident stated that drops had been placed in the ear for five days and that the ear was supposed to be flushed, but it never happened. The MDS Coordinator and DON both confirmed that the ordered ear lavage was not carried out, and the DON stated that following physician orders was important to resident well-being. The facility also failed to complete a fall risk evaluation after a resident’s third fall. The resident’s care plan identified the resident as being at risk for falls related to weakness, impaired mobility, impaired gait, and confusion, and the record documented three falls. An SBAR form showed an unwitnessed fall in the evening, but the fall risk evaluations reviewed by the DON did not include one for that fall. The DON stated the facility did not complete a fall risk evaluation for the unwitnessed fall and confirmed that the facility’s policy was to complete a fall risk evaluation after each fall. The facility further failed to follow a DNR order for a resident with severe cognitive impairment. The resident’s record included a POLST signed by the resident representative indicating Do Not Attempt Resuscitation/Allow Natural Death, and the resident’s orders also reflected DNR. Despite this, the progress note documented that when the resident was found pale with no pulse and no respirations, CPR was initiated, 911 was called, and the resident later died. During interview, the LVN and DON both stated that the POLST indicated DNR and that CPR should not have been performed, and the DON confirmed that staff did not follow the physician’s order for life-sustaining treatment.
Unsafe food storage and labeling practices in Kitchen 1
Penalty
Summary
Kitchen 1 failed to follow safe food storage practices during observation, interview, and record review. A gallon of ClassicGourmet classic Caesar dressing with a Best By date of 01/02/26 was observed in Refrigerator #3 with half of its contents remaining. During the same tour, the Dietary Supervisor stated the dressing should have been checked and should not have been accepted from the vendor, and explained that an expired dressing could cause stomachache, diarrhea, cramps, or vomiting. In the dry goods storage room, an unlabeled and undated 16-gallon clear plastic storage bin containing about one-fourth of ready-to-eat corn flakes with raisins was observed on open shelving. Two uncovered half-sheet pans of facility-baked yellow cake were also observed stored on top of a clear plastic bin of beans. The Dietary Supervisor stated the corn flakes were from the original manufacturer’s bulk bag and should have been labeled with an open date and use-by date immediately, and stated the cakes were left uncovered because they were cooling. The Dietary Supervisor later stated the facility did not have a designated cooling area for baked goods, and the Registered Dietician stated the cakes could have been stored in a cart rather than on top of the bean bin in the open shelving rack. Facility policy required food items in storage to be labeled and dated, opened refrigerated salad dressing to be stored for one month, and opened ready-to-eat cereals to be stored for two months.
Failure to Complete Ordered PT and OT Evaluations
Penalty
Summary
Resident 56 was admitted with diagnoses including malignant neoplasm of unspecified site of unspecified female breast and secondary malignant neoplasm of brain. The resident’s H&P dated 3/15/2026 indicated the resident could make needs known but could not make medical decisions. The physician’s order summary dated 3/12/2026 included orders for OT to evaluate and treat as indicated and PT to evaluate and treat as indicated. During interview and record review, the Director of Rehabilitation reviewed Resident 56’s Net Health record and stated there was no documentation that either the PT or OT evaluation had been completed. The DOR stated that if the evaluations were not documented, they were not done. The facility’s Rehabilitation Policy & Procedures - Evaluation & Plan of Care stated that therapy services must be based on an initial evaluation by a clinician and that the evaluation process should be initiated within 72 hours of the physician’s order.
Unlabeled Personal Care Item Stored in Shared Restroom
Penalty
Summary
The facility failed to implement infection prevention and control practices by not ensuring that personal care items for four sampled residents were labeled and stored properly. During observation, a shared room for Residents 72, 80, 16, and 70 had Enhanced Barrier Precaution signage posted at the door and a PPE cart outside the room. Inside the shared restroom, an unlabeled 8-ounce Essentials Cleanse Shampoo & Body Wash was found stored on the sink. Resident 72 had diagnoses including CVA and hemiplegia/hemiparesis following cerebral infarction, and the H&P stated the resident could make needs known but could not make medical decisions. The MDS indicated moderately impaired cognitive skills for daily decision making and substantial to maximal assistance with toileting hygiene, showering/bathing, and personal hygiene. Resident 80 had diagnoses including cerebral infarction and hemiplegia/hemiparesis following cerebral infarction affecting the right non-dominant side; the H&P stated the resident had capacity to understand and make decisions, while the MDS indicated moderately impaired cognitive skills for daily decision making. Resident 16 had diagnoses including hemiplegia/hemiparesis following cerebral infarction and cerebral infarction, with the H&P stating the resident did not have capacity to understand and make decisions; the MDS indicated intact cognitive skills for daily decision making and dependence for toileting hygiene, showering/bathing, and personal hygiene. Resident 70 had diagnoses including PVD and anemia, with the H&P stating the resident had capacity to understand and make decisions and the MDS indicating intact cognitive skills. CNA 3 stated the shampoo and body wash should have been labeled with a resident's name and kept at the bedside so staff would know who it belonged to, and the Infection Preventionist stated leaving the unlabeled item in the restroom could result in cross contamination because four residents shared the restroom.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the ombudsman of Resident 9’s transfer to an acute hospital. Resident 9 was admitted to the facility on 8/20/2024 with diagnoses including COPD and generalized weakness. The resident’s MDS dated 2/23/2026 indicated intact cognition and independence with bed mobility. A physician’s order dated 3/11/2026 documented that Resident 9 was transferred to the GACH due to possible stroke or sepsis. During an interview on 3/27/2026, the Social Services Director stated the facility needed to notify the Ombudsman of the transfer because Resident 9 was a resident at the facility, and stated that the importance of notifying the Ombudsman of resident transfers was for the safety of the resident. The facility’s policy and procedure titled Discharge Planning Process dated 3/2026 did not indicate the process for ombudsman notification for resident transfer to the GACH.
Inaccurate Hearing Assessment on MDS
Penalty
Summary
Resident 7 was not accurately assessed for hearing on the MDS. The face sheet showed the resident was admitted with diagnoses including atrial fibrillation, dysphagia, and generalized muscle weakness. The H&P dated 3/18/2025 indicated the resident had the capacity to understand and make decisions. The MDS dated [DATE] documented intact cognition and moderate assistance with several activities of daily living, but the hearing, speech, and vision section indicated minimal difficulty hearing. During an observation and bedside interview on 3/26/2026, Resident 7 gestured for the surveyor to come closer and stated, "Speak louder and put your mask down so I can hear you. I have had trouble hearing from before I got here [the facility]. They [facility] were putting drops in my ear for five days and were supposed to flush my ear out, but that never happened." During interview and record review, the MDS Coordinator stated Resident 7's hearing should have reflected moderate difficulty and that the assessment should be accurate. The DON stated accuracy of resident assessment was important to make sure residents were taken care of appropriately. The facility policy stated resident assessments would be comprehensive, accurate, and conducted initially and periodically as part of an ongoing process.
Failure to Care Plan Resident Hearing Difficulty
Penalty
Summary
The facility failed to develop an individualized person-centered care plan for Resident 7 that addressed the resident’s hearing difficulty. Resident 7 was admitted with diagnoses including atrial fibrillation, dysphagia, and generalized muscle weakness. The history and physical dated 3/18/2025 indicated the resident had the capacity to understand and make decisions, and the MDS indicated cognition was intact and that the resident required moderate assistance with toilet hygiene, upper body dressing, and transfers. The MDS also indicated Resident 7 had the ability to hear with minimal difficulty. During an observation and bedside interview on 3/26/2026, Resident 7 gestured for the surveyor to come closer and stated, “Speak louder and put your mask down so I can hear you. I have had trouble hearing from before I got here [to the facility].” During a concurrent record review, the MDS Coordinator stated Resident 7 did not have a care plan that addressed the hearing difficulty. The facility policy stated the interdisciplinary team develops a comprehensive person-centered care plan for each resident within 7 days of completion of the MDS and that it includes measurable objectives and timeframes to meet needs identified in the comprehensive assessment.
Failure to Inform Resident of Medications During Pass
Penalty
Summary
The facility failed to ensure licensed nursing staff informed a resident of the type of medication being administered during medication pass, as required by the facility’s Med Pass policy. Resident 79 was admitted with diagnoses including type 2 diabetes mellitus and parkinsonism, and the history and physical indicated the resident had the capacity to understand and make decisions. On 3/26/2026 at 8:29 AM, an LVN prepared seven oral medications for Resident 79’s 9 AM medication pass and brought them to the resident’s room. The LVN told the resident that the 9 AM medications would be administered, but did not tell the resident the types of medications being given. During interview, the LVN stated residents needed to be informed of the types of medications they were administered. The DON stated it was standard nursing practice to inform residents what type of medications were administered because it was a patient’s right to know, and that an alert, awake, and oriented resident could notify the nurse if there was an error with the medications being administered. The facility’s undated Med Pass policy stated to explain to residents the type of medication being administered.
Failure to Provide Communication Support for a Mandarin-Speaking Resident
Penalty
Summary
The facility failed to ensure that one sampled resident, who spoke Mandarin and did not speak English, was provided a communication tool or other resources to effectively communicate needs to staff. The resident was re-admitted with diagnoses including traumatic subdural hemorrhage and abnormalities of gait and mobility, and was documented as alert and oriented to person only. The resident’s Social Services Assessment and MDS both identified Mandarin as the resident’s primary and preferred language, and the MDS also noted adequate hearing and need for maximal assistance with several activities of daily living. During an observation, the resident smiled and nodded but did not respond to questions asked in English. Family members stated the resident communicated in Mandarin and did not speak English. When an LVN provided blood sugar testing and insulin administration, the LVN communicated through gestures and did not attempt to use a communication tool. The LVN stated a communication board should have been used to communicate thoroughly with the resident. The DON stated communication tools were important to properly communicate with residents and ensure their needs were met. The facility policy indicated interpreter services and communication boards were to be provided for non-English speaking residents, and that attempts would be made to write in the resident’s native tongue using available staff, family members, and community resources.
Failure to Provide Needed Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to ensure that Resident 42, who was unable to carry out activities of daily living, was properly groomed. Resident 42 was admitted with diagnoses including heart failure, essential hypertension, and abnormalities of gait. The care plan, initiated 3/8/2026, identified an ADL self-care performance deficit and noted personal hygiene routines that included being shaved and having hands washed. The MDS dated 3/13/2026 indicated the resident had moderately impaired cognitive skills for daily decision making and required moderate to maximal assistance with ADLs. The H&P dated 3/17/2026 stated the resident could make needs known but could not make medical decisions. During observation on 3/24/2026, Resident 42 was seen with unshaven facial hair, long fingernails, and dark brown blacking paste under the nails. In a concurrent interview, the resident stated they often asked to be shaved but it was not always done, did not like having a beard, and said the nails were so long that no one cut them; the resident also pointed to scratch marks on the arms and forehead from the nails. The LVN stated the fingernails were not clean, the resident’s hair and beard needed to be shaved, and the long fingernails had dirt underneath them. The LVN further stated long fingernails were not acceptable because they could result in scratches, cuts, and infection. The DON stated ADLs were important to keep residents clean and with good hygiene, and that long fingernails were not acceptable because they were a sign of poor hygiene and could lead to infections. The facility policy stated residents unable to carry out ADLs would receive necessary services to maintain grooming, personal hygiene, and oral hygiene.
Low Air Loss Mattress Left on Static Mode for Resident with Sacral PI
Penalty
Summary
The facility failed to ensure a low air loss mattress was set to intermittent pressure mode for one of four sampled residents, Resident 43, who had an unstageable pressure injury to the sacral region. Resident 43 was admitted with diagnoses that included an unstageable PI of the sacral region and generalized muscle weakness. The Braden Scale dated 3/2/2026 indicated a score of 15, showing mild risk for pressure injuries. The history and physical dated 3/3/2026 documented an unstageable PI on the right sacrum measuring 4.5 cm by 5 cm, and the MDS dated 3/6/2026 indicated intact cognition and maximal assistance with all bed mobility. The physician order in the order recap report dated 3/9/2026 directed use of a low air loss mattress for wound healing every shift, with setting by weight or comfort for the unstageable PI. During observation, the mattress was found set on static mode, and RN 2 stated the mattress was set based on weight or comfort. RN 2 later stated the mattress needed to be set to intermittent pressure and not static mode to promote healing of the resident's PI, and that static mode was only used during care such as position changes, diaper changes, or baths because it kept the mattress firm. The DON also stated the mattress needed to be set on alternating pressure and not static mode to promote healing. The manufacturer's manual described alternating as the normal alternating function and static as a mode that does not alternate and keeps the mattress firm and always inflated.
Failure to Supervise Residents While Smoking
Penalty
Summary
The facility failed to supervise two sampled residents while they were smoking in the patio's designated smoking area. Resident 82 was admitted with diagnoses including right knee effusion, muscle weakness, and schizoaffective bipolar disorder. Resident 82's H&P indicated the resident had the capacity to understand and make decisions, and the MDS showed the resident smoked one to two times a day. Resident 82's care plan identified a potential risk of injury related to smoking, but it did not state whether supervision was required while smoking. Resident 106 was admitted with diagnoses including acute pancreatitis, muscle weakness, difficulty walking, and nicotine dependence. Resident 106's H&P indicated the resident had the capacity to understand and make decisions, and the MDS showed the resident smoked four to six times a day. Resident 106's care plan identified potential risk of injury related to smoking, risk for impaired cognitive function or thought processes, assistance needs with ambulation and mobility, and potential behavioral problems related to psychosis, but it did not state whether supervision was required while smoking. Surveyors observed Resident 82 smoking unsupervised at 8:39 AM, and later observed Resident 82 and Resident 106 smoking unsupervised at 1:16 PM. The HRM stated residents are sometimes left unsupervised if they are awake, alert, and oriented to smoke independently, while the IPN and DON stated the facility's smoking policy required staff supervision in the smoking area and that the residents should not have been left unsupervised.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for two sampled residents. Resident 10 was admitted with diagnoses including dementia and metabolic encephalopathy, and the MDS dated 3/3/2026 indicated moderately impaired cognitive skills for daily decision making and impairment of one upper extremity. During a 3/24/2026 observation, Resident 10 was lying in bed facing the left side, with a touchpad call light placed on the resident’s right side near the right ear. Resident 10’s right hand was contracted and turned inward toward the wrist, and the resident was heard saying, “oh my God, the bottom of my feet hurt.” RN 2 stated it would be hard for Resident 10 to find the call light because it was placed behind the resident and that it needed to be placed close to the resident’s left hand because the resident was able to use the left hand and ask for assistance. Resident 41 was re-admitted with diagnoses including hemiplegia and hemiparesis following cerebral infraction and need for assistance with personal care. The MDS dated 1/22/2026 indicated Resident 41 was cognitively intact, dependent with bed mobility, fully dependent with transfers, and fully dependent with toilet use. During a 3/24/2026 observation, Resident 41 was lying in bed with a touch-pad call light observed close to the resident’s right shoulder. Resident 41 stated, “can you please call the nurse; I cannot reach the call light. I can't use my right arm. I can't even go across my body with my left arm. How am I supposed to reach that [call light]?” The DON stated call lights should be within reach for residents to communicate their needs to staff, and the facility policy stated to place the call device within the resident’s reach before leaving the room.
Failure to Reposition Resident With Stage 4 Pressure Ulcer and Report Refusals
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a Stage 4 pressure ulcer was turned and repositioned in accordance with the resident’s care plan. The resident had diagnoses including muscle weakness and a displaced subtrochanteric fracture of the left femur, moderately impaired cognitive skills, and required assistance with mobility and activities of daily living. The care plan identified the resident as having a pressure ulcer or risk for pressure ulcer development related to weakness, pain, impaired mobility, incontinence, and risk for impaired circulation, and directed staff to monitor, remind, and assist the resident to turn and reposition every two hours and as needed. A separate care plan also documented that the resident was resistive to care related to non-compliance with turning and repositioning, with interventions to educate the resident on possible outcomes of not complying with treatment or care. Surveyor observations showed that after wound care and a bed bath, CNAs turned and positioned the resident slightly toward the right side with a pillow placed lengthwise from the left side of the neck under the left shoulder down to the waistline, and this same positioning was observed at multiple times later that day. During an interview, a CNA stated they had changed the resident’s diaper but did not reposition the resident because the resident refused to turn, and the CNA did not inform the charge nurse or any licensed nurse of this refusal. The Treatment Nurse and DON both stated that CNAs are expected to follow the repositioning schedule and report refusals to the charge nurse so that licensed staff can provide education, encouragement, and follow-up. The facility’s policy on Prevention and Management of Pressure Injuries indicated that residents should be encouraged to reposition and that the facility will promote a turning schedule and reposition frequently as needed.
Failure to Provide Premedication for Pain Before Wound Care and Bed Bath
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate pain management before performing wound care and a bed bath for a resident with a Stage 4 pressure ulcer. The resident was originally admitted with diagnoses including muscle weakness and a displaced subtrochanteric fracture of the left femur and had moderately impaired cognitive skills, requiring significant assistance with activities of daily living. The physician’s orders included a pain management consult and hydrocodone-acetaminophen 5-325 mg every six hours as needed for severe pain rated 7–10. During an observed wound care session, the treatment nurse asked the resident for a pain rating, and the resident reported a pain level of 7. As certified nursing assistants repositioned the resident and removed a pillow from under the heels, the resident moaned and verbalized pain in the groin and back, stating, "You're doing everything else to hurt me." Despite this, the treatment nurse proceeded with wound care without administering pain medication or allowing time for any pain medication to take effect. Later in the same session, while wound care was ongoing, the treatment nurse again asked the resident for a pain rating, and the resident continued to report a pain level of 7. The nurse asked if the resident wanted them to stop and return after pain medication, but the resident responded, "Let's get this done," and the procedure continued without premedication. After wound care, a bed bath was provided by certified nursing staff, during which the resident cried out in pain three times. By the end of the observation period, the resident stated having experienced 45 minutes of pain. Interviews with the treatment nurse and the DON confirmed that pain management prior to treatment is considered important to promote comfort and prevent suffering, and the facility’s pain management policy states that the facility will identify circumstances when pain can be anticipated and implement pharmacologic and/or non-pharmacologic interventions to manage or prevent pain, which did not occur in this instance.
Failure to Follow Enhanced Barrier Precautions Between Residents During Bed Baths
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control procedures, specifically Enhanced Barrier Precautions (EBP), when providing care to a resident with a multidrug-resistant organism (MDRO) and then to another resident. One resident had been admitted with diagnoses including UTI and DM and had an active diagnosis of MDRO per the MDS, with a physician’s order placing the resident on EBP due to an indwelling urinary catheter and MDRO. Facility policy required gown and glove use for high-contact care activities such as bathing, hygiene, and changing linens for residents on EBP, and further required changing gloves and gowns after each resident encounter and performing hand hygiene. Surveyors observed a CNA providing a bed bath to the MDRO-positive resident while wearing a protective gown. After completing the bed bath, the CNA did not remove the gown or perform hand hygiene, but instead only changed gloves and then prepared and proceeded to provide a bed bath to another resident who was dependent on staff for showering/bathing and had diagnoses including infection and inflammatory reaction due to cardiac and vascular devices and endocarditis. During interview, the CNA stated they wore the same gown and only changed gloves between the two residents because they believed the first resident was not on any precautions and that the gown was “just for prevention.” The Infection Prevention Nurse later confirmed that the first resident was on EBP for a history of MDRO in the urine and that EBP was intended to protect that resident and others from acquiring MDRO, consistent with the facility’s written policies.
Failure to Ensure Ongoing Physician Management of Insulin Therapy for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician assessment and continued management of a high‑risk medication regimen for a resident with diabetes mellitus. The resident was admitted with diagnoses including diabetes mellitus with ketoacidosis and long‑term use of insulin, and had documented decision‑making capacity and intact cognitive skills. A Hemoglobin A1C result showed a level of 13.6%, and the resident had clear speech and was usually understood and able to understand others. Review of the physician orders and Medication Administration Records showed that the resident had orders for Humalog insulin before meals and Lantus insulin every 12 hours beginning in October, with those orders ending on 11/20/2025. The records indicated there were no physician orders for any oral or injectable diabetes medications from 11/20/2025 through 11/27/2025, and the MAR confirmed that no diabetes medications were administered during that eight‑day period. Subsequent insulin orders were not written until 11/28/2025. Progress notes dated 11/27/2025 documented that the resident was not on any diabetic medications because the hospital insulin orders had ended on 11/20/2025, and that the physician could not be reached. The note also indicated that the resident and a home health agency administrator requested that discharge be held until an insulin regimen was established. In interviews, an RN and the DON acknowledged that the resident did not receive insulin for eight days, that nursing staff should have clarified the discontinuation of insulin with the physician, and that it was facility policy and part of the nursing job responsibilities to monitor residents, recognize abnormalities, and consult with the physician regarding resident evaluation and care needs.
Delayed Response to Call Lights and Toileting Requests
Penalty
Summary
Facility staff failed to promptly respond to call lights and requests for toileting assistance for two residents. One resident, admitted with peripheral vascular disease, sickle-cell disease, and muscle wasting, reported waiting 30 minutes to 1 hour for staff to answer the call light, particularly in the afternoon. This resident required supervision or touch assistance for personal and oral hygiene, bathing, and dressing, and had no cognitive impairment. Another resident, with diagnoses including lymphoma, urinary tract infection, and muscle weakness, required substantial to maximal assistance for bathing and supervision or touch assist for dressing and toileting hygiene. This resident reported waiting 2 hours for staff to respond to a call light when needing to use the bathroom, timing the delay by watching the clock in the room. Interviews with both residents confirmed repeated delays in staff response to call lights, with one resident specifically noting the need for toileting assistance during the prolonged wait. The Director of Nursing acknowledged that residents should not have to wait 30 minutes for call lights to be answered. Facility policies reviewed indicated that staff are expected to answer call lights within a reasonable time and treat residents with dignity and respect, allowing flexibility in daily activities and choices.
Failure to Create Plan of Action for Resident Council Concerns
Penalty
Summary
The facility failed to ensure that a Plan of Action form was created in response to concerns raised by residents during resident council meetings, as required by the facility's own policy and procedure. Specifically, meeting minutes from two separate resident council meetings documented complaints from residents about long wait times for staff assistance during shift changes. Although the Activities Director reported these complaints to the Director of Nursing, no Plan of Action form was submitted as mandated by the facility's policy. The facility's policy states that the Activities Director is responsible for referring resident concerns to appropriate personnel and that a Plan of Action form should be submitted to address these concerns or suggestions. The lack of a Plan of Action form for the complaints about wait times meant that the concerns raised by residents were not formally addressed or tracked according to established procedures.
Failure to Document Physician Visit in Resident Medical Record
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for one resident when they did not document the resident's visit to a urologist in the medical record. The resident, who had diagnoses including urinary tract infection, type 2 diabetes mellitus, and hypertension, was admitted and later readmitted to the facility. According to the Minimum Data Set, the resident had no cognitive impairment and was dependent on staff for lower body dressing, bathing, and toileting hygiene. The resident's granddaughter confirmed accompanying the resident to a urologist appointment, but there was no documentation of this visit in the resident's progress notes. During a review of the facility's policy and procedure on charting and documentation, it was found that physician visits and orders are required to be documented in the resident's record. The Director of Nursing confirmed that the appointment was not documented as required. This omission resulted in the resident's medical record lacking a summary of the physician visit, leading to incomplete information in the resident's chart.
Failure to Promptly Respond to Call Light Compromises Resident Dignity
Penalty
Summary
Staff failed to promptly respond to a resident's call light, resulting in a lack of timely assistance for personal care needs. The resident, who had diagnoses including end stage renal disease, hypoglycemia, muscle weakness, and mobility issues, required substantial to maximal assistance with toileting, bathing, and dressing, and was frequently incontinent. The care plan directed staff to anticipate and meet the resident's needs, ensure the call light was within reach, and encourage its use for assistance. During observations, the resident activated the call light for a brief change and reported that staff typically took 30 minutes or longer to respond, sometimes making the resident wait up to an hour. The resident also stated that staff would sometimes defer assistance until their rounds were complete or would instruct the resident to wait for the assigned staff member, even if another staff member was available. Multiple staff were observed walking past the resident's room while the call light was on, and the call light remained unanswered for at least 10 minutes during the surveyor's observation. Interviews with CNAs revealed that licensed nurses generally did not assist with answering call lights or simple resident requests, leaving the responsibility to CNAs. Both the LVN and DON stated that all staff were responsible for answering call lights and emphasized the importance of prompt responses to meet residents' needs. The facility's policy required staff to answer call lights within a reasonable time, listen to the resident's request, and respond appropriately, but these procedures were not followed in this instance.
Delayed Response to Call Light and Incontinence Care for Resident Needing ADL Assistance
Penalty
Summary
A deficiency occurred when a resident who required assistance with activities of daily living (ADLs), including toileting and incontinence care, did not receive timely help from facility staff. The resident, who had diagnoses such as end stage renal disease, hypoglycemia, muscle weakness, and mobility issues, was assessed as needing substantial to maximal assistance with toileting and other ADLs and was frequently incontinent. The care plan specified that staff should anticipate and meet the resident's needs, ensure the call light was within reach, and encourage its use for assistance. On the day of the incident, the resident activated the call light to request a brief change but reported that staff typically took 30 minutes or longer to respond, sometimes making the resident wait up to an hour for assistance. Observations confirmed that the call light remained unanswered for at least 11 minutes while multiple staff members walked by the room. The resident also reported that if the assigned staff member was unavailable, other staff would instruct the resident to wait for the assigned staff, further delaying care. Interviews with CNAs revealed that licensed nurses generally did not assist with answering call lights or simple resident requests, leaving the responsibility to CNAs. However, both the LVN and DON stated that all staff were responsible for answering call lights promptly, emphasizing the importance of meeting residents' needs quickly. The facility's policy required that residents unable to perform ADLs receive necessary services to maintain their abilities, but this was not followed in the observed case.
Untrained Staff Operate Tube Feeding Machines Against Policy
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding received care from staff who were trained and competent in feeding tube management according to facility policies and procedures. The resident in question was admitted with diagnoses including dysphagia and failure to thrive, and had a gastrostomy tube for nutrition. The resident was dependent on staff for all activities of daily living and received tube feeding as ordered by a physician. During observations, a Certified Nursing Assistant (CNA) was seen turning the resident's tube feeding machine from 'hold' to 'run' after providing care, despite facility policy and staff statements indicating that only licensed nurses are permitted to operate tube feeding machines. Interviews with CNAs revealed that it was common practice for them to put tube feeding machines on hold and then resume feeding after care, even though they were not trained or authorized to do so. The Director of Staff Development and the Director of Nursing both confirmed that CNAs are not allowed to operate tube feeding machines, and that this task falls outside their scope of practice. A review of the facility's policies and procedures, as well as CNA job descriptions and competency checklists, confirmed that tube feeding management is not included in CNA training or competencies. The facility's policy specifies that only licensed nurses are to provide care and maintenance of gastrostomy tubes. This failure to follow policy and ensure staff competency had the potential to affect not only the resident observed but all residents receiving tube feeding in the facility.
Untrained Staff Operated Tube Feeding Equipment
Penalty
Summary
The facility failed to ensure that only appropriately trained and licensed staff operated enteral feeding equipment for a resident who required tube feeding. The resident, who was dependent on others for all activities of daily living and had a gastrostomy tube due to dysphagia and failure to thrive, was observed receiving care from a CNA who operated the tube feeding machine. Specifically, the CNA turned the tube feeding machine from 'hold' to 'run' after providing care, despite facility policy and scope of practice limitations. Interviews with staff revealed inconsistent practices and understanding regarding the operation of tube feeding machines. One CNA admitted to turning the machine on to avoid disturbing residents with alarms, while another CNA stated it was common practice to put the machine on hold and then resume feeding after care. However, both the LVN and the Director of Staff Development confirmed that only licensed nurses were permitted to operate tube feeding machines, and that CNAs were neither trained nor authorized to do so. A review of the facility's policies, CNA job descriptions, and competency checklists confirmed that tube feeding machine operation was not included in CNA training or competencies. The facility's policy specified that gastrostomy tube care and maintenance were licensed nurse procedures. The deficiency was identified through direct observation, staff interviews, and review of facility documentation, demonstrating a failure to ensure that only competent, authorized staff provided care related to enteral feeding equipment.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for one resident who had a gastrostomy tube and was dependent on staff for all activities of daily living. The resident's medical records indicated diagnoses of dysphagia and failure to thrive, and the resident was receiving tube feeding for nutrition. During an early morning observation, a CNA provided care to the resident without wearing an isolation gown, despite a posted sign indicating the resident was on EBP. The CNA later acknowledged forgetting to put on the gown, even though facility policy and staff interviews confirmed that EBP, including the use of gown and gloves, was required for residents with indwelling medical devices such as G-tubes. Interviews with the Director of Staff Development, Infection Prevention Nurse, and Director of Nursing all confirmed that staff were expected to follow EBP protocols, including wearing masks, gowns, and gloves when providing care to residents with tubes, wounds, or other devices. The facility's policy specified that EBP should be used during high-contact care activities to prevent the indirect transfer of multidrug-resistant organisms. The failure to follow these precautions was directly observed and confirmed through staff interviews and policy review.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent and manage pressure ulcers for three residents. Resident 62, who had a Stage 4 pressure ulcer, was not turned and repositioned by CNA 1 as required. Despite being assessed as moderate risk for pressure ulcers, Resident 62 was observed lying on her back for extended periods without repositioning. CNA 1 did not seek assistance from other staff to reposition Resident 62, even when the resident became agitated and resistant to care. The care plan for Resident 62 indicated the need for regular repositioning, but this was not consistently followed, and the interdisciplinary team did not address the resident's refusal of care. Resident 183, assessed as high risk for pressure ulcers, was also not repositioned adequately. CNA 2 failed to turn Resident 183 every two hours as required, and the resident was observed lying on her back for extended periods. When CNA 2 attempted to reposition Resident 183, the resident resisted, and CNA 2 did not seek further assistance. The care plan for Resident 183 was generic and did not include specific interventions for the new pressure injury. The facility's policy required regular turning and repositioning, but this was not adhered to, leading to the development of pressure injuries on Resident 183's buttocks. Resident 32, who had a Stage 3 pressure ulcer, was found with the low air loss mattress pump turned off, contrary to the care plan and facility policy. The LAL mattress was intended to prevent further skin breakdown, but CNA 2 was unaware of how long the pump had been off. This oversight could have contributed to the worsening of Resident 32's pressure ulcer. The facility's policy required the LAL mattress to be plugged in and functioning to prevent skin breakdown, but this was not followed, compromising the resident's care.
Infection Control Deficiencies in PPE Use and Personal Item Labeling
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program (IPCP) for nine sampled residents, leading to potential cross-contamination and transmission of infections. Unlabeled personal toiletries were found stored in a shared restroom used by four residents, contrary to the facility's policy that requires personal items to be labeled and kept at the resident's bedside. This oversight was confirmed during an observation and interview with a Certified Nursing Assistant (CNA) and the Infection Preventionist Nurse (IPN), who emphasized the importance of labeling and proper storage for infection control. Additionally, staff failed to adhere to proper personal protective equipment (PPE) protocols while caring for residents on contact isolation. Observations revealed that CNAs did not change gowns and gloves between assisting different residents in a cohorted room, despite the presence of contact precautions signage. The IPN confirmed that staff should change PPE between residents to prevent cross-contamination, especially when dealing with residents on contact isolation for infections like Vancomycin-resistant enterococci (VRE). Furthermore, a CNA entered a room with residents on contact precautions for Candida Auris without wearing the required gown and gloves. The CNA only wore PPE when providing direct care, contrary to the facility's policy that mandates PPE use upon entering the room of residents on contact precautions. The IPN reiterated the necessity of wearing PPE to prevent the spread of C. auris, a highly transmissible fungus, and to ensure the safety of both residents and staff.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for three residents, leading to the unnecessary administration of antibiotics. Resident 10 was readmitted with diagnoses including sepsis and dementia. Despite being administered Ertapenem Sodium, there was no Infection Surveillance - V2 Form (ISV2F) completed to determine if the resident met McGreer's criteria for antibiotic use. The Infection Prevention Nurse (IPN) acknowledged the oversight and the absence of necessary documentation to justify the antibiotic administration. Resident 72, admitted with sepsis and muscle weakness, was prescribed Ampicillin Sodium. However, the ISV2 form was not completed to confirm if the resident met the criteria for antibiotic treatment for cellulitis or other infections. The IPN admitted to not following up with the resident's physician regarding the antibiotic use, which is crucial to ensure the criteria are met and to prevent antibiotic resistance. Resident 134, diagnosed with acute respiratory failure and diabetes, was given Zosyn for pneumonia. Similar to the other cases, the ISV2 form was incomplete, and there was no indication that the resident met McGreer's criteria for antibiotic use. The facility's policy on antibiotic stewardship, which aims to promote appropriate antibiotic use and reduce resistance, was not adhered to in these cases, leading to potential risks of antibiotic resistance.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 283, which could potentially delay or prevent the resident from obtaining necessary care and services. Resident 283 was admitted to the facility with diagnoses including an unspecified head injury, muscle weakness, and epilepsy. The resident's Minimum Data Set (MDS) indicated that their cognition was moderately impaired, and they required substantial to maximal assistance with activities of daily living and mobility. During an observation, the call light for Resident 283 was found on the floor and underneath the bed, making it inaccessible to the resident. Interviews with a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that call lights should be within reach to enhance resident safety and well-being. The facility's policy and procedure on call lights emphasized the importance of leaving the call device within the resident's reach before leaving the room.
Inadequate Staffing Leads to Delayed Care and Loss of Dignity
Penalty
Summary
The facility failed to provide sufficient staffing to ensure timely incontinence care and maintain the dignity of two residents, Resident 233 and Resident 39. Resident 233, who was admitted with diagnoses including heart failure and type 2 diabetes, required substantial assistance for toileting hygiene. On multiple occasions, Resident 233's family member observed delays of 30 minutes to an hour for changing soiled briefs. On one occasion, Resident 233 was left in a soiled diaper for two hours, causing a missed physical therapy session. Interviews with staff revealed that the facility was short-staffed, particularly during evening and night shifts, with CNAs responsible for an unusually high number of residents. Resident 39, diagnosed with Alzheimer's disease and requiring maximal assistance for personal hygiene, was observed following CNAs in the hallway, asking for help. The CNAs, busy with other tasks, did not immediately assist Resident 39, with one CNA acknowledging that they should have asked another staff member to help. The Director of Nursing confirmed that all residents should be treated with dignity and respect, as per the facility's policy. The facility's staffing policy indicated that adequate staff should be maintained to meet residents' needs, which was not adhered to in this instance.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with respect and dignity when a Certified Nursing Assistant (CNA) was observed dismissing the resident's request for assistance. The incident involved a resident diagnosed with Alzheimer's disease, generalized muscle weakness, and abnormal posture, who was admitted to the facility with severely impaired cognition and required maximal assistance with personal hygiene and transfers. During an observation, the resident, while sitting in a wheelchair, followed CNAs in the hallway, asking for help. One CNA responded by saying, 'not right now, I am busy,' and turned away to continue passing water to other residents. Interviews with other CNAs and the Director of Nursing (DON) revealed that the response to the resident's request was inappropriate. Another CNA expressed that they would not have turned their back on the resident and acknowledged the resident's confusion and need for assistance. The DON emphasized that all residents, including those who are confused, should be treated with compassion, empathy, and dignity. The facility's policy on resident rights, revised in January 2025, mandates that all residents be treated with kindness, dignity, and respect.
Inadequate Call Light System for Resident with Parkinson's
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident by not ensuring the resident's call light system was accessible and functional. The resident, who was admitted and readmitted with diagnoses including metabolic encephalopathy, Parkinson's disease, and muscle weakness, was observed to have rigid hands and was dependent on others for activities of daily living and mobility. Despite these conditions, the resident was provided with a push call light system, which was not suitable given the resident's hand rigidity. During interviews, both an LVN and the DON acknowledged the inadequacy of the call light system for the resident's needs. The LVN noted that a tap or mechanical pad call system would be more appropriate, allowing the resident to alert staff for assistance effectively. The DON emphasized the importance of assessing residents' needs for suitable call systems at admission and periodically thereafter to ensure effective care and a safe environment. The facility's policy on accommodating residents' needs included providing appropriate call lights, but this was not adhered to in the case of the resident.
Failure to Conduct PASARR Screening for New Admission
Penalty
Summary
The facility failed to ensure that a newly admitted resident, identified as Resident 45, was pre-screened for PASARR (Preadmission Screening and Resident Review) prior to admission. This screening is a federal requirement to ensure that individuals with mental disorders or intellectual disabilities are placed in facilities that can provide appropriate care. Resident 45 was admitted with multiple diagnoses, including unspecified dementia, psychosis, depression, and schizophrenia, which are considered mental disorders. Despite these diagnoses, there was no record of a PASARR in Resident 45's medical record, as confirmed by both the Admission Coordinator and the Director of Nursing during interviews and record reviews. The absence of a PASARR meant that the facility lacked critical information to determine if Resident 45 required specialized care or rehabilitative services for their mental disorder. The facility's policy and procedure documents, including the Admission Practice and PASARR policies, clearly state the requirement for a PASARR to be completed upon admission. However, this was not adhered to in the case of Resident 45, as the necessary screening was not conducted, and the documentation was not retained in the resident's medical record. This oversight had the potential to impact the quality of care provided to Resident 45, as the facility was not fully informed of the resident's mental health needs.
Failure to Provide Documented Activities for a Resident
Penalty
Summary
The facility failed to provide adequate activities for Resident 62, which could potentially affect the resident's psychosocial well-being. During observations, Resident 62 was seen lying in bed for extended periods without engagement in activities. Interviews with the Activities Director (AD) revealed that the facility offers one-to-one (1:1) activities for residents who do not participate in group activities. However, the AD was unable to provide documentation of any activities provided to Resident 62, as the Activities Staff (AS) do not document activities in general. Further investigation showed that there was no Admission Activities Assessment for Resident 62, and the Minimum Data Set (MDS) assessment of daily and activity preferences was left blank. This lack of documentation meant that the AS had no guidance on what activities would be meaningful for Resident 62. The facility's policy and procedure on Quality of Life, Activities Program, emphasizes the importance of a resident-centered activities program to maintain or improve residents' well-being, but this was not implemented for Resident 62.
Failure to Follow Bowel Management Orders
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident, identified as Resident 42, who was experiencing bowel management issues. The resident, who had a history of occasional constipation, was not properly managed as per the physician's orders. The orders included the administration of Milk of Magnesia (MOM) and Dulcolax suppository for constipation management. However, the resident refused MOM, and the facility staff did not notify the physician of this refusal or the resident's multiple bowel movements. The Licensed Vocational Nurse (LVN) administered a Dulcolax suppository without verifying the frequency of the resident's bowel movements or consulting the physician, which was against the physician's orders. This action was taken despite the resident having multiple bowel movements and expressing discomfort. The resident reported feeling anxious and miserable due to the bowel issues and was eventually transferred to a General Acute Care Hospital for further evaluation after experiencing blood in the stool. The Director of Nursing (DON) confirmed that the LVN did not follow the physician's orders and failed to document the resident's refusal of MOM or notify the physician of the resident's condition. The facility's policies required any change in a resident's condition to be communicated to the physician, and medications to be administered as prescribed. The failure to adhere to these protocols resulted in the resident's condition worsening and necessitating hospital transfer.
Failure to Post Oxygen Signage for Resident on Continuous Oxygen Therapy
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the posting of oxygen signage for a resident receiving supplemental continuous oxygen. Resident 233, who was admitted with multiple diagnoses including respiratory failure and COPD, was receiving continuous oxygen therapy at 2 liters per minute via nasal cannula. Despite the ongoing oxygen therapy, there was no oxygen warning signage posted in Resident 233's room, which is a requirement per the facility's policy to ensure safety and alert residents and visitors to the presence of oxygen. During an observation, it was noted that Resident 233 was awake and alert in bed with the oxygen therapy in place, yet the necessary signage was absent. An interview with an LVN confirmed that the signage should have been posted to prevent the use of flammable materials, such as cigarettes, which could pose a fire risk. The facility's policy, as reviewed, clearly indicated the need for NO SMOKING/OXYGEN IN USE signs as part of the equipment for administering oxygen safely.
Inadequate Sanitizing Solution in Kitchen
Penalty
Summary
The facility failed to ensure that one of the two sanitation buckets in the kitchen contained an adequate amount of quaternary sanitizing solution, which is essential for disinfecting key areas used in food preparation for residents. During an observation, a staff member checked the quaternary sanitizing solution in two buckets using a test strip. The test strip indicated that bucket 1 had a concentration of 100 ppm, which is below the required range of 200 ppm to 400 ppm for effective disinfection. This deficiency was confirmed through interviews and record reviews, where it was noted that the solution's effectiveness was compromised due to an insufficient concentration. Further investigation revealed that the reduced effectiveness of the sanitizing solution in bucket 1 was due to an excessive number of washcloths in the bucket, which absorbed the disinfectant and reduced its potency. The Registered Dietician confirmed that the presence of too many or heavily soiled washcloths could compromise the solution's efficacy. The Director of Dining Services emphasized the importance of maintaining proper quaternary solution levels to prevent cross-contamination and ensure a safe environment for residents. The facility's policy required the solution to be tested every shift or when cloudy and replaced if below 200 ppm, which was not adhered to in this instance.
Absence of DON at QAPI Meeting
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) attended the Quality Assurance Performance Improvement (QAPI) quarterly meeting, as required. During a review of the QAPI Sign in Sheet and an interview conducted on February 6, 2025, it was confirmed that the DON was not present at the QAPI meeting held on January 24, 2025. The Administrator acknowledged that the DON's presence was necessary for planning and monitoring nursing-related services, as the DON is the head of the nursing department. The Administrator admitted that an acting DON should have attended the meeting when the previous DON left. The facility's 2025 QAPI Plan specified that the DON was designated as the clinical care sub-committee leader, highlighting the importance of their role in the QAPI leadership team.
Excessive Resident Occupancy in Room
Penalty
Summary
The facility failed to comply with regulations by accommodating more than the allowed number of residents in a single room. Specifically, room [ROOM NUMBER] was observed to have six residents, exceeding the maximum limit of four residents per room. This was confirmed during an observation and interview with Treatment Nurse 1, who stated that there were six residents in the room. The Administrator, during an interview, acknowledged that the room initially had five beds and residents when they were hired in August 2024. However, a sixth bed was added on January 20, 2025, and a sixth resident was admitted the following day. The Administrator also admitted that the facility lacked a policy specifying the maximum number of residents per room, contributing to this oversight.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's fall history, which is crucial for developing an effective care plan. The resident, who was admitted and readmitted with diagnoses including psychosis, muscle weakness, gait abnormalities, and dementia, had a documented history of falls. However, discrepancies were found in the fall risk assessments conducted on different dates. On January 22, 2025, the resident was assessed as high risk for falls, having experienced three or more falls in the past three months. Yet, a subsequent assessment on January 31, 2025, inaccurately documented the resident as having only one or two falls, changing the risk category from high to medium. The inaccuracy was acknowledged by an LVN during a review, who admitted to documenting the fall history incorrectly. This error was significant as it altered the resident's fall risk category, potentially impacting the care and interventions provided. The facility's policy emphasizes the importance of accurate and comprehensive assessments to inform care plans, but this was not adhered to in this instance, as evidenced by the inaccurate documentation of the resident's fall history.
Failure to Revise Care Plans for Fall and Pressure Injury
Penalty
Summary
The facility failed to revise the care plan for Resident 59 after the resident sustained a fall on two separate occasions, on 12/23/2024 and 12/31/2024. Despite the falls, the care plan, which was created on 10/22/2024, was not updated to address the resident's increased risk for falls. Interviews with the Licensed Vocational Nurse and Registered Nurse revealed that the care plan should have been updated after each fall to reassess the resident's needs and address any contributing factors to prevent future incidents. The facility's policy on fall prevention also indicated that a care plan update should be generated following a fall. The facility also failed to revise the care plan for Resident 183 after the resident developed a pressure injury and refused to turn and reposition. The care plan, initiated on 2/5/2025, included generic interventions that were not specific to the resident's new pressure injury. Observations showed that the resident was resistant to repositioning, and the care plan did not include specific interventions to address this refusal. The Registered Nurse acknowledged that the care plan needed to be more specific to encourage the resident to turn and reposition. The facility's policy on comprehensive person-centered care planning requires the interdisciplinary team to develop a care plan with measurable objectives and timeframes to meet the resident's needs identified in the comprehensive assessment. The failure to update the care plans for both residents resulted in unmet individualized needs and had the potential to affect their physical well-being.
Failure to Prevent Falls Due to Inadequate Supervision and Bed Positioning
Penalty
Summary
The facility failed to maintain a safe environment for two residents, leading to potential and actual falls. Resident 233, who was at medium risk for falls due to muscle weakness and mobility issues, had an order for their bed to remain in the lowest position as a safety precaution. However, during an observation, the bed was found in a high position, contrary to the care plan and facility policy, which increased the risk of injury in the event of a fall. Resident 59, diagnosed with psychosis, muscle weakness, and dementia, was identified as high risk for falls. On a specific date, Resident 59 attempted to get out of bed without assistance, leading to a fall. Despite the presence of a Licensed Vocational Nurse (LVN) who was informed of the resident's need for assistance, the LVN did not intervene, stating it was not her responsibility. This lack of teamwork and communication among staff members contributed to the fall, as the LVN prioritized medication administration over immediate resident safety. Interviews with staff and residents highlighted a pattern of inadequate collaboration and communication, particularly involving the LVN's reluctance to perform basic care tasks. The Director of Nursing and other staff emphasized the importance of teamwork and the LVN's role in ensuring resident safety, even in situations requiring immediate intervention. The facility's policies on fall management and resident safety were not effectively implemented, resulting in a failure to prevent falls and ensure a hazard-free environment.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to adhere to its policy and procedure for medication administration, specifically concerning controlled medications, for five residents. Licensed Vocational Nurse 1 (LVN 1) did not sign the controlled medication count sheets after administering medications to these residents, which is a critical step in ensuring proper medication management and accountability. Additionally, LVN 1 did not sign the Medication Administration Record (MAR) for two residents after administering their controlled medications, further compounding the issue of inadequate documentation. During interviews, LVN 1 acknowledged the importance of signing the controlled medication count sheet to prevent potential medication errors, such as double dosing or underdosing, and to ensure accountability in case of medication diversion. The Director of Nursing (DON) emphasized the necessity of following the MAR and accurately documenting medication administration to maintain resident safety and prevent medication diversion. The facility's policy, revised in January 2025, clearly outlines the requirement for immediate documentation of controlled medication administration, including the date, time, amount, and nurse's signature, which was not followed in these instances.
Failure to Implement Care Plan for Abdominal Binder
Penalty
Summary
The facility failed to implement a care plan for the use of an abdominal binder for a resident, which was necessary to prevent the dislodgement of the resident's gastrostomy tube. The resident, who was admitted with diagnoses including cerebral infarction, malignant neoplasm of the colon, and gastrostomy status, was observed wearing an abdominal binder. However, there was no care plan in place for its use, despite a physician's order being obtained on 1/21/2025. The resident's Minimum Data Set indicated significant communication and self-care dependencies, highlighting the need for consistent care planning. Interviews with facility staff revealed a lack of awareness and implementation of a care plan for the abdominal binder. The Case Manager was unsure if a care plan existed, and the Director of Nursing acknowledged that a care plan should be created with any new physician's order. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan with measurable objectives and timeframes, which was not adhered to in this case, leading to the potential for inconsistent care for the resident.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the spread of infections among residents, staff, and visitors. This deficiency was observed in the actions of a Licensed Vocational Nurse (LVN 1) and a Certified Nursing Assistant (CNA 3) who did not adhere to the facility's hand hygiene policy. LVN 1 was seen fist bumping with a resident in the dining room and then proceeded to handle meal trays without performing hand hygiene. Similarly, CNA 3 assisted a resident with their lunch tray and touched various surfaces in the resident's room, but did not wash hands or use hand sanitizer before delivering a meal tray to another resident. Interviews with LVN 1 and CNA 3 revealed that both staff members were aware of the importance of hand hygiene in preventing infection spread but failed to comply with the protocol. The Interim Director of Nursing confirmed that staff are required to perform hand hygiene before and after handling meal trays, touching residents, or interacting with equipment in resident rooms. The facility's failure to ensure proper hand hygiene practices was corroborated by the Centers for Disease Control and Prevention's guidelines, which emphasize the necessity of cleaning hands before and after patient contact and after touching contaminated surfaces.
Failure to Provide Proper PICC Site Care
Penalty
Summary
The facility failed to provide appropriate care for a resident's peripherally inserted central catheter (PICC) site, as per the physician's orders and facility policy. The resident, who was admitted with cellulitis and diabetes mellitus, had orders to monitor the PICC site every 8 hours and administer specific IV antibiotics. However, the IV Medication Administration Record indicated that the PICC site was not cleaned, and the dressing was not changed until a day after the medication administration. Observations revealed that the PICC site had dried blood, and the dressing was falling off, which was not addressed by the nursing staff. Interviews with the resident and nursing staff revealed that the nurses did not check or change the dressing on the PICC site as required. The resident mentioned that the nurses would take care of the dressing later, and the nurses admitted to not assessing the PICC site during medication administration. The Interim Director of Nursing confirmed that PICC site dressings should be changed every 7 days or as needed if soiled, and that RNs must check the site during medication administration to prevent infections. The facility's policy also emphasized the importance of regular dressing changes to minimize infection risks.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate fall prevention measures for a resident who was at high risk for falls, as indicated by their care plan and physician's orders. The resident, who had a history of metabolic encephalopathy, muscle weakness, multiple sclerosis, and contractures, experienced a fall resulting in a skin tear. Despite a physician's order and care plan intervention to provide bilateral floor mats, these were not present at the resident's bedside during an observation. Interviews with staff revealed a lack of communication and adherence to fall prevention protocols, as there was no fall precaution sticker or floor mats to indicate the resident's fall risk. The facility's policy required physician orders to be reviewed and implemented accurately, yet this was not followed in the case of the resident's floor mats. Staff interviews highlighted inconsistencies in communication about fall risks during shift changes and huddles. A family member noted that the mats had been removed due to tripping hazards, but could not recall when this occurred. The absence of floor mats, despite the resident's high fall risk score, demonstrated a failure to adhere to the care plan and physician's orders, potentially placing the resident at risk for further falls and injuries.
Failure to Provide Timely Care for Breast Lump
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident who developed a lump in her left breast. On April 17, 2024, a Licensed Vocational Nurse (LVN) noted the lump but did not promptly notify the resident's Primary Care Provider (MD 1) or develop a care plan to address the issue. Despite the resident's repeated requests for medical attention, the facility staff did not follow up with the necessary interventions, including scheduling a mammogram as recommended by MD 1. The resident, who had a history of multiple sclerosis, hydronephrosis, and cerebral palsy, experienced severe pain under her left breast and rib cage on July 1, 2024, leading to her transfer to a General Acute Care Hospital (GACH). At the hospital, a mass suspicious for malignancy was discovered, and a subsequent biopsy confirmed infiltrating ductal carcinoma. The facility's failure to reassess the resident's condition and communicate effectively with MD 1 resulted in a significant delay in diagnosis and treatment. Interviews with facility staff, including LVNs and the Director of Nursing (DON), revealed a lack of adherence to the facility's policies and procedures regarding change of condition reporting and care planning. The staff did not document or carry out the physician's orders for a mammogram, and the Social Services Director was not informed to schedule the necessary appointment. This oversight contributed to the resident's prolonged distress and delayed cancer diagnosis.
Failure to Respect Resident's Rights and Dignity
Penalty
Summary
Certified Nursing Assistants (CNAs) 2 and 3 failed to respect and honor the rights of a resident, referred to as Resident 2, by not listening to her request regarding how she wished to be turned in bed. Resident 2, who had intact cognition and was dependent on staff for various activities, including turning in bed, had requested to be turned a certain way due to her existing medical conditions, including a broken left arm. Despite her request, the CNAs insisted on turning her in a manner they deemed appropriate, disregarding her instructions and leading to a physical altercation. During the incident, Resident 2 experienced severe pain in her right elbow after being turned by the CNAs, which resulted in a displaced oblique fracture of the mid humeral diaphysis. The fracture was suspected to be exacerbated by Resident 2's severe osteoporosis, a condition that was not being treated with medication at the time. The incident led to Resident 2 being transferred to a General Acute Care Hospital for further evaluation and treatment, including surgery to repair the fracture. Interviews with Resident 2 and her roommate, as well as a review of the facility's policies, highlighted the failure of the CNAs to treat Resident 2 with dignity and respect. The Director of Nursing acknowledged that staff should listen to residents and respect their rights, emphasizing the importance of treating residents with dignity as a basic human right. The facility's policy on Resident Rights mandates that residents be treated with consideration and respect, which was not adhered to in this case.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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