Avalon Villa Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 12029 Avalon Blvd, Los Angeles, California 90061
- CMS Provider Number
- 056023
- Inspections on file
- 71
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 73
Citation history
Health deficiencies cited at Avalon Villa Care Center during CMS and state inspections, most recent first.
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.
A cognitively intact, quadriplegic resident who was dependent on staff for ADLs reported that a CNA became upset when the call light was used and directed profanity toward the resident during care. The resident informed the AD the next day, stated the treatment and language were disrespectful, and requested to speak with the SSD. The AD texted the SSD about the complaint, but the SSD did not meet with the resident that day due to other duties and did not speak with the resident until two days later. This sequence of events shows the facility did not follow its grievance policy requiring the Administrator and staff to make prompt efforts to resolve grievances submitted orally or in writing.
A resident with COPD, asthma, diabetes, and influenza, and a POLST allowing selective treatment and possible hospital transfer, experienced repeated episodes of O2 desaturation, vomiting, coughing, and respiratory distress. Earlier in the evening, an RN supervisor administered O2 via non-rebreather and nasal cannula, improved the resident’s O2 saturation, and notified the physician, who ordered comfort measures and continued monitoring. Later that night, documentation showed the resident became partially arousable, unresponsive to commands, and unable to accept medications, and was later observed with labored breathing and on O2, with vital signs unobtainable, before being found unresponsive with no pulse. During these later changes, staff did not document any further interventions or physician notification, despite facility policies and nursing job descriptions requiring prompt reporting and documentation of significant changes in condition.
A resident with mobility limitations and intact cognition required one-person assistance for bathing and had documented preferences for morning showers on specific days and shaving every two days. Staff instead followed a bed-based shower schedule on the evening shift, repeatedly telling the resident they were too busy or not assigned when he requested daytime showers and shaving. The resident reported not being offered showers on multiple occasions, including after returning from an out-of-facility pass on a scheduled shower day. CNAs and an LVN described a paper shower-sheet system that was not integrated into the EHR, did not clearly verify whether showers occurred, and was maintained by the DSD outside the medical record; missing shower sheets for the resident on scheduled days, along with the DSD’s acknowledgment that staff did not accommodate the resident’s preferences and that communication about showers was unclear, demonstrated the failure to provide and document ADL care as planned.
A resident who lacked decision-making capacity was administered Depakote for behavioral symptoms without documented informed consent from their responsible party. Staff interviews and record reviews confirmed that the required process for obtaining and verifying informed consent was not followed, despite facility policy mandating involvement of the resident's representative in medication decisions.
A resident with schizoaffective disorder, schizophrenia, and depression was prescribed Depakote for mood disorder with angry outbursts, but staff discontinued required behavior monitoring and documentation, preventing proper assessment of the medication's effectiveness as outlined in the care plan and facility policy.
Two residents with mobility impairments who used wheelchairs were not provided with enough space in their shared room to maneuver safely and comfortably. This resulted in their wheelchairs frequently bumping into each other, causing frustration and difficulty moving around, as confirmed by staff observations and resident interviews.
Three residents with significant care needs were left soiled for extended periods due to staff delays, lack of prompt response to call lights, and inadequate communication among staff. These delays occurred despite facility policies requiring prompt toileting assistance and placed residents at risk for discomfort and loss of dignity.
A resident admitted with hemiplegia and muscle weakness was identified as at risk for skin breakdown using the Braden Scale, but the care plan to address this risk was not initiated until nearly a month after admission. As a result, interventions such as repositioning, nutrition, and skin care were not formally documented or tracked in a timely manner.
A resident with a diabetic heel ulcer and multiple comorbidities was repeatedly observed bearing weight on both legs despite a non-weight bearing order. Nursing staff and the wound care specialist provided education, but the care plan was not updated to address the resident's ongoing noncompliance, as confirmed by the treatment nurse, RN, and DON. Facility policy required care plan revisions when a resident's condition changed, but this was not done.
A resident with diabetes, osteomyelitis, and impaired cognition had a non-weight bearing order for the right foot documented by a wound care specialist, but this order was not transcribed into the electronic health record. The order was communicated verbally and in writing to the treatment nurse, and the medical records and QA nurse were also responsible for reviewing and notifying staff of new orders. However, the order was not entered, resulting in the resident's care plan lacking this essential instruction.
A nurse held a scheduled dose of a muscle relaxant for a resident with multiple health conditions after administering a narcotic pain medication, without notifying the physician or documenting the reason. Facility policy required physician notification and order clarification before altering medication regimens, but this was not followed, resulting in an unapproved change to the resident's prescribed medications.
Licensed nursing staff failed to accurately document medication administration and blood pressure readings for a resident with complex medical needs. Midodrine was documented as given when blood pressure was above ordered parameters, and doses that were held were sometimes recorded as administered. Additionally, the reason for holding a muscle relaxant was not documented when it was withheld due to concurrent administration of a narcotic. These actions did not meet facility policy for accurate and complete documentation.
A kitchen staff member was observed working in the dishwashing area near food preparation without properly secured facial hair covering, as required by facility policy. The staff member was unaware that his hair netting had slipped out of place, and the Assistant Dietary Supervisor acknowledged the risk of hair contamination in food or on clean dishes.
A live cockroach was observed in a hallway near the kitchen, an area regularly used by residents, indicating the facility failed to maintain an effective pest control program. Although the pest control company provided regular services focused on the kitchen, pest sightings in the hallway were not addressed, and there was no documentation that recommendations were implemented or that problem areas were treated.
A resident who was cognitively intact but dependent on staff for ADLs was left in a soiled diaper for more than five hours, despite expressing discomfort and requesting to be changed. Staff failed to provide timely assistance, with one CNA stating she was too busy and another only notifying the assigned CNA. This inaction violated facility policy requiring prompt care and resulted in the resident feeling undignified.
A resident with multiple medical conditions and requiring maximum assistance with ADLs experienced a significant delay in call light response, remaining in a soiled diaper for over five hours. Staff failed to answer the call light within the facility's required timeframe, and care was not provided promptly despite the resident's visible discomfort and requests for assistance.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A staff member was hired and worked as an LVN without a valid nursing license, administering controlled substances to several residents, including one with osteomyelitis. The facility failed to verify the staff member's credentials as required by policy, and this was acknowledged by the DSD, DON, and Administrator.
A staff member was hired and worked as an LVN without a valid license, administering controlled substances such as Norco, Oxycodone, Percocet, and Tramadol to multiple residents with serious conditions including fractures, osteomyelitis, and paraplegia. The facility failed to verify the staff member’s credentials, instead relying on a license belonging to another individual, and did not follow its own policy requiring license verification before employment.
A resident with major depressive disorder and moderate cognitive impairment was prescribed escitalopram, but staff did not implement or document required behavior monitoring to assess the medication's effectiveness. Interviews with nursing staff and the DON confirmed that behavior monitoring was not ordered or conducted, despite facility policy requiring such monitoring for psychotropic medication use.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with major depressive disorder and moderate cognitive impairment did not have a care plan addressing their MDD, including non-pharmacological interventions, despite being dependent on staff for most activities and receiving antidepressant medication. Staff interviews and policy review confirmed the lack of a required, person-centered care plan for this diagnosis.
Two nurses were unable to demonstrate competency in the facility's abuse reporting policies, including not knowing the abuse coordinator or their mandated reporter responsibilities, despite having completed required training and documentation. This was identified through interviews and record reviews, revealing a gap between training and staff understanding of abuse reporting procedures.
After an assault on a CNA by three unauthorized individuals who gained access to the facility's gated parking lot, staff interviews revealed that the security code was not changed following the incident. Staff suspected that a coworker provided the code to the perpetrators, and concerns were raised about ongoing safety risks due to the unchanged code.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with severe cognitive impairment and a history of traumatic brain injury and psychoactive substance use was found in another resident's room going through personal belongings. Despite this incident, the facility did not develop or implement a care plan to address the resident's behavior, as confirmed by the DON and a review of care plans and facility policy.
A resident with multiple diagnoses, including TBI and major depressive disorder, experienced an episode of verbal and physical aggression. While the DON stated that the incident was verbally reported to the PCP and psychiatrist, there was no documentation in the clinical record to confirm this communication, contrary to facility policy requiring such documentation.
Two residents who were unable to leave their rooms were not provided with daily dietary menus, preventing them from making informed choices about their meals or knowing about alternative options. Staff interviews confirmed that menus were not available in resident rooms, and some staff were unaware of the menu details. Both residents had specific dietary needs and were capable of making decisions, but were not given the opportunity to exercise their rights regarding meal selection.
A medication error occurred when a medication cup containing zinc oxide cream was left unattended on a resident's bedside table. The resident, who had moderate cognitive impairment and required substantial assistance, was unaware of the cream's presence. The nurse responsible for administering the medication left it at the bedside while waiting for a CNA, contrary to facility policy requiring medications to be stored securely and inaccessible to residents.
Surveyors found that food items in the kitchen refrigerator were not consistently labeled with thawing dates and times, and several opened items were not properly sealed or dated with opened and discard dates. The Dietary Supervisor acknowledged that these practices could result in staff not knowing how long food had been thawed or opened, contrary to facility policy requiring all refrigerated and frozen foods to be covered, labeled, and dated.
A resident with a history of stroke and alcohol dependence was allowed to leave the facility on pass without completing the required Release of Responsibility for Leave of Absence Form. As a result, staff did not have information on the resident's destination, contact details, or expected return time, and the resident did not return as planned. Staff interviews confirmed the form was not completed as per facility policy.
A facility failed to verify the probationary status of an RN's license and did not ensure completion of required competencies, supervision, or documentation audits as mandated by the licensing board. Key staff were unaware of the RN's restrictions, and the facility did not follow its own policies for license verification and competency assessment, potentially affecting the care of all residents.
A resident with multiple chronic conditions experienced chest pain and was administered nitroglycerin, but the facility failed to accurately document the timing of the change of condition, medication administration, and vital signs. Staff interviews and record reviews revealed inconsistencies between the actual events and the times recorded in the medical record, resulting in incomplete and inaccurate documentation.
A resident with major depressive disorder requested a room change due to distress caused by a roommate. Despite reporting the issue to a CNA and an LVN, the request was not promptly addressed, leading to continued emotional distress. The facility's policy requires room changes upon request, but staff failed to act in a timely manner.
A resident with skin itchiness and swelling did not have an individualized care plan developed by the facility, leading to worsening conditions and multiple hospitalizations. Despite the resident's fluctuating capacity to understand and make decisions, no interventions were in place to manage the skin issues, as confirmed by an LVN. The facility's policy mandates comprehensive care plans, which were not implemented in this case.
A resident experienced inadequate care due to the facility's failure to document a Change of Condition assessment and carry out a physician's order for a dermatology consult. The resident's skin condition worsened, leading to multiple hospitalizations. Interviews revealed the resident felt neglected, and the facility did not create a care plan or follow up on necessary appointments.
A resident with hypertension and hyperlipidemia did not receive scheduled doses of Losartan and Aspirin due to a failure by the LVN to administer the medications before the resident left for an appointment. The facility's policy requires timely medication administration, which was not followed, potentially endangering the resident's health.
The facility failed to maintain safe and sanitary restrooms for two residents, leading to discomfort and potential health risks. A resident avoided using Restroom A due to fear of infection, while another resident's family reported unsafe conditions in Restroom B, including holes in the wall and deteriorating floors. The facility's policy on providing a homelike environment was not upheld.
The facility failed to ensure the safety of several residents, including a resident who eloped twice despite being high risk for wandering and elopement. The facility did not implement a care plan or conduct necessary monitoring upon readmission. Additionally, a resident trespassed with a large knife, and lighters were not securely stored, posing risks to residents. A fall mat was also not placed at a resident's bedside, increasing fall risk.
The facility discharged three residents without their consent or knowledge, failing to confirm their safety or intent to leave. One resident returned with a weapon, highlighting the unsafe discharge process. The facility did not follow its policy requiring a resident's request and acknowledgment of risks for an AMA discharge.
The facility failed to provide advance notice of discharge to three residents, leading to their discharge against medical advice (AMA) without proper communication or preparation. One resident with a broken thigh bone and depression was discharged AMA after not returning from an approved leave, without confirming his intention to be discharged. Another resident with muscle weakness and diabetes was discharged AMA without contact information or confirmation of his intention to leave. A third resident with vascular disease left on approved leave, informed staff of his intent to return, but was discharged AMA without expressing a desire to leave permanently.
The facility failed to conduct required competency skills evaluations for three CNAs and two licensed nurses upon hire and annually. The DSD and DON acknowledged the absence of evaluations, which are crucial for assessing staff performance and identifying training needs to ensure quality resident care.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper handling of water pitchers and failure to change an IV dressing for a resident. Dirty water pitchers were found stored in a clean area, and staff were confused about the color-coding system for clean and dirty pitchers. Additionally, a resident's IV dressing had not been changed since insertion, contrary to the facility's policy, increasing the risk of infection.
The facility failed to develop and implement comprehensive care plans for several residents, leading to significant deficiencies in care. A resident with Alzheimer's disease eloped twice due to the absence of a care plan addressing their high risk for wandering and elopement. Other residents at high risk for wandering and elopement also lacked appropriate care plans, leaving them vulnerable. Additionally, the facility did not address critical care needs such as medication use, bed rail safety, fall prevention, and nutritional requirements, resulting in inadequate monitoring and potential harm.
The facility failed to follow the standardized lunch menu and provide correct food textures for residents on modified diets. Substitutions were made without RD approval due to missing ingredients, and residents on mechanical soft and pureed diets received incorrect food consistencies, posing a choking risk. The RD and Administrator were unaware of these issues, highlighting a lack of communication and adherence to facility policies.
The facility failed to serve food at appetizing temperatures, affecting 115 residents. A resident complained about cold pork chops, and a test tray confirmed food temperatures were below acceptable levels. The Dietary Supervisor noted delays in serving contributed to the issue.
The facility failed to maintain safe food storage and preparation practices, with unmonitored thaw dates for nutritional supplements, use of unpasteurized eggs, and improper date labeling of food items. Kitchen equipment was not cleaned as per schedule, posing risks of pest infestation and microorganism growth. Additionally, resident food from outside was stored without proper date labeling, increasing the risk of consuming spoiled food.
Two residents experienced a violation of their rights when a CNA failed to provide requested assistance. One resident, feeling cold, was denied an extra blanket and clean linens, while another resident's call light request for a wheelchair or walker was ignored. The facility's policies on resident rights and call light response were not followed, leading to deficiencies in care.
A facility failed to obtain informed consent from a resident or their representative before starting treatment with Cymbalta, a psychotropic medication prescribed for nerve pain. The resident had the capacity to make decisions, but there was no documentation of informed consent, as required by the facility's policy. The DON acknowledged the oversight, noting staff were unaware that consent was needed even if the medication was not for behavioral management.
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.
Failure to Promptly Address Resident Grievance About Disrespectful CNA Behavior
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance/complaint filing policy requiring the Administrator and staff to make prompt efforts to resolve resident grievances. A resident with quadriplegia and other neurologic and musculoskeletal conditions, who was cognitively intact and dependent on staff for ADLs, reported that a CNA became upset when the resident pressed the call light and used profanity (“f***”) while providing ADL care. The resident stated this occurred in the evening and that he felt the CNA’s language and behavior were disrespectful. The next day, the resident reported this incident to the Activities Director (AD), stating he did not like how the CNA treated him and that the language used around him was disrespectful, and he requested to speak with the Social Services Director (SSD). The AD acknowledged that the resident reported the CNA’s use of the F word during care and that such behavior was not acceptable. The AD texted the SSD the same day, informing her that the resident wanted to speak with her regarding a complaint involving a nurse, and the SSD responded that she was in a meeting. The AD did not know whether the SSD spoke with the resident or whether the Administrator was informed. The SSD later stated she did not see the resident that day because she was very busy with new admissions and meetings and did not have the opportunity to speak with the resident until two days later. The DON stated that resident complaints should be addressed immediately and grievances resolved in a timely manner. The facility’s written grievance policy stated that the Administrator and staff will make prompt efforts to resolve grievances submitted orally or in writing, but in this case the resident’s grievance about staff behavior and language was not promptly addressed.
Failure to Intervene and Notify Physician for Resident With Respiratory Decline and Altered Consciousness
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services that met professional standards of practice for a resident with COPD, asthma, diabetes, and influenza, who had a POLST indicating DNR status but allowing selective treatment, including IV therapies, non-invasive positive airway pressure, and hospital transfer if comfort needs could not be met. The resident’s care plan directed staff to observe for signs and symptoms of respiratory insufficiency such as anxiety, confusion, and shortness of breath and to refer to the physician as needed. Physician orders allowed oxygen at 2 L/min via nasal cannula as needed for oxygen saturation below 93% on room air. On one day, a Change in Condition (COC) evaluation documented that the resident’s O2 saturation dropped to 88%, and oxygen was administered via non-rebreather mask, then changed to nasal cannula when stabilized. Progress notes later that evening documented another O2 desaturation to 88%, with oxygen via non-rebreather at 3 L/min improving saturation to 96%, then changed to nasal cannula with O2 saturation at 95–96%. The RN supervisor reported notifying the physician of the low O2 saturation and oxygen administration, and the physician ordered to make the resident comfortable and continue monitoring. Additional progress notes indicated that around 6:00 p.m. the resident had an episode of vomiting and continuous coughing, with O2 saturation less than 94%; the RN supervisor was notified and oxygen was administered, and the resident was monitored for decline. Later that night, progress notes documented that the resident was unable to accept medication due to partial waking and was unresponsive to commands, but there was no documentation of any interventions provided or physician notification regarding this change in condition. A subsequent note around 11:46 p.m. stated that on initial rounds the resident was observed on a non-rebreather mask at 8 L/min with labored breathing, and attempts to obtain vital signs were unsuccessful; on reassessment at approximately 11:46 p.m., the resident was unresponsive with no palpable pulse and no chest rise, and no code was initiated due to DNR status. This note also did not document any interventions for the labored breathing or physician notification at that time. A CNA reported observing the resident with labored breathing around 11:00 p.m. and notifying an LVN, who responded that the resident was a DNR. The physician later stated he had been informed earlier of the low O2 saturation that stabilized with oxygen and had instructed staff to continue monitoring, and that he was surprised to receive a later call informing him of the resident’s death, stating the resident should have been transferred to the hospital if the condition had not improved. The DON acknowledged that the resident had another significant change in condition and should have been transferred. Facility policies and job descriptions required prompt physician notification of significant changes in condition and documentation of such changes, which were not followed in this case.
Failure to Honor Resident Shower Preferences and Document ADL Care
Penalty
Summary
The facility failed to ensure that a resident received showers and grooming in accordance with his assessed needs and stated preferences. The resident was admitted with multiple mobility- and strength-related diagnoses, including generalized muscle weakness, abnormal gait and mobility, prior stroke, lumbar spondylosis, prior right femur fracture with internal fixation, and right hip osteoarthritis. His care plan for activities of daily living indicated he required one-person assistance with most bathing tasks due to decreased strength, limited balance, and reduced functional independence. An MDS assessment documented intact cognition, independence with eating and personal hygiene, and a need for maximal assistance with bathing and dressing. An IDT conference note recorded that the resident preferred showers before 10:00 a.m. on Mondays, Tuesdays, Wednesdays, Thursdays, and Saturdays, and preferred to be shaved every two days. Despite these documented needs and preferences, staff followed a shower schedule based on bed assignment rather than the resident’s individualized preferences. A CNA reported that residents in Bed A were scheduled for showers on Mondays and Thursdays during the 3 p.m. to 11 p.m. shift and that she reminded the resident his showers were scheduled for that shift when he requested showers during the day. The CNA stated the resident frequently asked for showers during the day and became upset when told of the evening schedule. The resident reported that he was not offered showers on several specific dates and that when he reminded staff, they told him they were too busy or not his assigned nurse, and they also refused to shave him when requested. He stated that on one scheduled shower day he left the facility in the morning and returned before lunch but was not offered a shower upon his return. The facility’s documentation and communication practices contributed to the missed showers and grooming. The CNA stated she was required to complete paper shower sheets and an ADL task flowsheet in the EHR, but the flowsheet did not indicate whether a shower was actually completed, and if a shower sheet was not completed and turned in, nursing staff would not know if a resident received a shower. An LVN confirmed that showers were documented only on shower sheets, which were reviewed and then sent to the Director of Staff Development (DSD), and that showers were not documented in the EHR; if a shower sheet was missing, there was no way to verify in the medical record that a shower occurred. The DSD stated that shower sheets, which listed multiple residents per page, were kept in her office and were not part of the resident’s medical record, and that there were no shower sheets for the resident for certain dates when showers were due. The DSD acknowledged that the CNA assigned on one of those dates did not offer the resident a shower, that staff were not accommodating the resident’s shower preferences, and that staff communication regarding showers was not clear. Facility policies on dignity, resident rights, and ADL support required that residents be groomed as they wished and receive appropriate assistance with hygiene in accordance with their plan of care.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from the responsible party prior to administering Depakote, an anticonvulsant medication, to a resident diagnosed with schizoaffective disorder, schizophrenia, and depression. The resident was determined to lack the capacity to make healthcare decisions, and a responsible party was designated to make such decisions on their behalf. Despite this, there was no documented verification that the responsible party was informed about the risks, benefits, and alternatives to Depakote before it was administered for mood disorder symptoms, specifically angry outbursts. Interviews with facility staff confirmed that the process for obtaining informed consent required the physician to explain the medication and its effects to the responsible party, with nursing staff responsible for verifying that consent was obtained before administration. Record review showed that while informed consent documentation existed for other antipsychotic medications, none was present for Depakote. Facility policies also required that residents or their representatives be informed and involved in medication management, including the right to refuse treatment, but this process was not followed in this instance.
Failure to Monitor and Document Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to consistently monitor and document the behaviors of a resident with a history of schizoaffective disorder, schizophrenia, and depression, who was prescribed Depakote for mood disorder manifested by angry outbursts. According to the resident's care plan, staff were required to monitor and document episodes of angry outbursts every shift to assess the effectiveness of the medication regimen. However, behavior monitoring was discontinued on 10/14/2025 and was not reordered, despite ongoing orders for Depakote and the continued need to evaluate behavioral symptoms. Record review and staff interview confirmed that the lack of behavior monitoring meant the healthcare team did not have the necessary information to determine the efficacy of the medication or to make informed decisions about potential dose adjustments. The facility's policy required staff to observe, document, and report on the effectiveness of interventions, including antipsychotic medications, but this was not followed for the resident in question.
Failure to Provide Adequate Space for Wheelchair Mobility
Penalty
Summary
The facility failed to provide adequate space and equipment to meet the needs of two residents who both required wheelchairs for mobility. Observations and interviews revealed that the room shared by these residents did not allow sufficient space for them to maneuver their wheelchairs without bumping into each other. Both residents had medical conditions affecting their mobility, including hemiplegia, hemiparesis, generalized muscle weakness, and foot drop. Documentation indicated that both residents had intact cognition or fluctuating capacity to make decisions, and both required moderate assistance with activities of daily living. The lack of space led to repeated incidents where their wheelchairs collided, causing frustration and making it difficult for them to move around their room safely and comfortably. Staff interviews, including those with the Social Services Director and the Administrator, confirmed that the room arrangement did not accommodate the residents' needs, resulting in miscommunication and disagreements between the residents. The facility's own policy required adaptation of the physical environment to meet individual needs and preferences, but this was not implemented in this case. The deficiency was directly observed by staff and corroborated by resident statements, with specific incidents such as a water pitcher being knocked over due to the lack of space.
Failure to Provide Timely Incontinence Care Compromising Resident Dignity
Penalty
Summary
The facility failed to provide timely incontinence care for three residents who were dependent on staff for toileting and hygiene, resulting in prolonged periods where residents remained soiled. One resident, with diagnoses including muscle weakness, ESRD, and impaired cognitive skills, was left sitting in a soiled incontinence pad for approximately six hours after a bowel movement. The resident had requested assistance multiple times, but after refusing care from the assigned CNA, no alternative staff was arranged in a timely manner. The CNA did not inform the charge nurse when unable to secure another CNA, resulting in a significant delay before care was provided. Another resident, who required partial to moderate assistance for toileting and was at risk for pressure ulcers, experienced a delay of about an hour before receiving incontinence care. The resident had requested to be cleaned and was told by the CNA that care would be provided after attending to another resident. Due to staff shortages, the resident remained soiled for an extended period, which the CNA acknowledged could place the resident at risk for skin breakdown and affect their dignity. A third resident, with hemiplegia and requiring substantial assistance for toileting, also experienced excessive wait times for incontinence care. The resident and a family member reported waiting up to an hour and a half for pericare, with the resident stating that staff did not change her throughout the night shift. The assigned CNA confirmed the delay, citing being occupied with other residents and additional duties. Facility policies reviewed indicated that staff were required to promptly respond to toileting requests and maintain residents' dignity, but these standards were not met in the cited incidents.
Delayed Care Plan for Skin Breakdown Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan in a timely manner for a resident who was at risk for skin breakdown. The resident was admitted with diagnoses including right hemiplegia, hemiparesis, and muscle weakness, and was identified as being at risk for skin breakdown based on a Braden Scale assessment conducted at admission. Despite this assessment, the care plan addressing the risk for skin breakdown was not initiated until nearly a month after admission. Interviews and record reviews confirmed that interventions such as repositioning every two hours, maintaining cleanliness, and providing proper nutrition were not formally documented or tracked due to the delayed care plan. The facility's policy required that a comprehensive, person-centered care plan be developed within seven days of the required assessment, but this was not followed, resulting in a lack of timely preventative measures and monitoring for the resident.
Failure to Update Care Plan for Noncompliance with Non-Weight Bearing Order
Penalty
Summary
The facility failed to update the care plan for a resident with a diabetic ulcer on the right heel, who was noncompliant with a non-weight bearing order. The resident, admitted with diagnoses including osteomyelitis, type-2 diabetes mellitus, and hypertension, was observed multiple times bearing weight on both legs and walking, despite recommendations from the wound care specialist and education provided by nursing staff. Documentation in the resident's records, including the Non-Pressure Injury Skin Problem Report and Skin/Wound Notes, indicated ongoing noncompliance with the non-weight bearing order. Interviews with the treatment nurse, RN, and DON confirmed that the resident's care plan had not been revised to address the noncompliance, even though the facility's policy required care plans to be updated as residents' conditions changed. The lack of care plan revision meant that interventions to address the resident's noncompliance were not implemented, as acknowledged by the staff involved in the resident's care.
Failure to Transcribe Non-Weight Bearing Order for Resident with Diabetic Foot Ulcer
Penalty
Summary
A deficiency occurred when a non-weight bearing order for a resident's right foot, as prescribed by the wound care specialist, was not transcribed into the resident's electronic health record. The resident, who was admitted with diagnoses including osteomyelitis, type-2 diabetes mellitus, and hypertension, had moderately impaired cognition and required significant assistance with activities of daily living. The resident also had diabetic foot ulcers requiring wound dressings. During review, it was found that the wound care specialist's visit note documented the non-weight bearing order, but this order was not entered into the resident's active orders. Interviews with the RN and DON revealed that the process for handling new orders involved verbal and written communication from the wound care specialist to the treatment nurse, who was responsible for entering the orders. Additionally, the medical records and QA nurse were expected to review the wound care notes and notify nursing staff of new orders. Despite these procedures, the non-weight bearing order was not transcribed, resulting in the absence of this critical instruction in the resident's care plan.
Failure to Notify Physician and Clarify Orders Before Holding Scheduled Medication
Penalty
Summary
A deficiency occurred when a licensed nurse failed to notify the physician and obtain clarification before holding a scheduled dose of methocarbamol, a muscle relaxant, for a resident with multiple medical conditions including muscle weakness, end stage renal disease, and impaired cognitive skills. The nurse held the 6 a.m. dose of methocarbamol after administering Norco, a pain medication, believing that muscle relaxants should not be given concurrently with narcotics due to the risk of respiratory compromise. However, there was no physician order or documentation supporting this decision, and the reason for holding the medication was not recorded in the Medication Administration Record or Nursing Progress Notes. Facility policy required that medications be administered as prescribed and that any concerns about medication appropriateness or potential adverse consequences be discussed with the attending physician or medical director. The Director of Nursing confirmed that nurses were expected to assess residents and administer medications as ordered unless otherwise specified by a physician, and that holding a scheduled medication without provider notification and order clarification did not meet facility expectations. This resulted in an unapproved alteration of the resident's medication regimen.
Failure to Accurately Document Medication Administration and Blood Pressure Readings
Penalty
Summary
Licensed nursing staff failed to ensure accurate and reliable documentation of medication administration for a resident with multiple complex medical conditions, including end stage renal disease, muscle weakness, and hypertension. The resident had physician orders for midodrine to be administered only if systolic blood pressure (SBP) was 110 or below, as well as orders for methocarbamol and Norco. However, the Medication Administration Record (MAR) showed that midodrine was documented as given on several occasions when the resident's SBP was above the ordered threshold. Interviews with nursing staff revealed that doses were sometimes held but mistakenly documented as administered, and in one instance, a nurse incorrectly recorded the resident's SBP. Additionally, there was a failure to document the reason for holding methocarbamol. One nurse held the medication due to concurrent administration of Norco, believing it was unsafe to give both at the same time, but did not record this rationale in the MAR or nursing notes. This omission meant that subsequent staff were not informed of the reason for the held dose. The facility's policies required that all services, medication administration, and changes in resident condition be accurately documented to ensure communication among the care team. The Director of Nursing confirmed that all MAR entries, blood pressure readings, and nursing notes should accurately reflect the care provided. The lack of accurate documentation and communication regarding medication administration and resident condition was acknowledged by staff and leadership as not meeting facility policy and professional standards.
Failure to Ensure Proper Hair Covering in Kitchen
Penalty
Summary
During an observation in the facility's kitchen, a staff member working as a dishwasher was seen with facial hair that was not properly covered by the required hair netting or beard restraint while working in the dishwashing area near the food preparation station. The staff member stated he was unaware that his hair covering had slipped out of place and believed his facial hair was still covered. The Assistant Dietary Supervisor confirmed that a hair covering not properly secured could result in hair falling into food, clean dishes, or the food preparation area, which would increase the risk of food contamination. Review of the facility's policy indicated that all food service employees must wear hair nets and/or beard restraints to prevent hair from contacting exposed food, clean equipment, and utensils.
Failure to Maintain Effective Pest Control Program Resulting in Cockroach Presence
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live cockroaches in a resident-accessible hallway near the kitchen. During an observation with the DON, a live cockroach was seen crawling on the wall in an area regularly used by residents to access the dining room and activity area. The DON acknowledged that the presence of cockroaches in this location created the potential for unsanitary conditions and the spread of pests into food preparation and resident living spaces. The facility's pest control company was reported to provide monthly services, and the maintenance supervisor was responsible for follow-up on pest issues. A review of pest control service invoices showed that weekly services were primarily focused on the kitchen, and pest sightings in the hallway had not been addressed because these areas were not prioritized. The maintenance supervisor could not provide information on the facility's efforts to implement pest control recommendations or ensure elimination of cockroaches. The administrator confirmed that while routine pest control services were conducted, there was no documentation that specific problem areas, such as the main hallway near the kitchen, were evaluated or treated. The facility's policy required maintaining an environment free of pests and rodents.
Resident Left in Soiled Diaper for Over Five Hours, Dignity Not Maintained
Penalty
Summary
A resident with a history of a left tibia fracture, COPD, diabetes mellitus, and schizophrenia, who was cognitively intact but required maximum assistance for activities of daily living, was left in a soiled diaper for over five hours. The resident was observed to be awake, fidgeting, and visibly uncomfortable, and expressed frustration about not being changed. Despite the resident's request for assistance, a CNA informed the resident that she would notify the assigned CNA but did not provide care herself. Another CNA later stated she was too busy with other residents to assist, acknowledging that the resident was not provided dignity or able to exercise her rights. Facility policy required that residents wait no longer than two minutes to be changed and emphasized treating residents with dignity, respect, and kindness at all times. The failure to provide timely incontinence care resulted in the resident feeling upset and undignified, directly contravening the facility's stated policies and procedures regarding resident rights and dignity.
Delayed Call Light Response and Resident Care
Penalty
Summary
Staff failed to answer a resident's call light in a timely manner, as observed when a call light and audible tone outside the resident's room went unanswered for approximately 27 minutes. The resident, who was admitted with diagnoses including a nondisplaced spiral fracture of the left tibia, COPD, diabetes mellitus, and schizophrenia, required maximum assistance with activities of daily living and had intact cognition. During the period of delay, the resident was found awake, fidgeting, and visibly uncomfortable, expressing frustration about having been left in a soiled diaper for more than five hours and requesting to be changed. A Certified Nurse Assistant (CNA) entered the room but did not provide care, stating she would notify the assigned CNA. The facility's policy, as confirmed by the Director of Nursing, required call lights to be answered within two minutes, and the written procedure indicated calls should be answered immediately. The delay in response was directly observed and confirmed through staff interviews and review of facility policy.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Unlicensed Staff Hired and Functioning as LVN
Penalty
Summary
The facility failed to ensure that its credentialing process was completed prior to hiring a staff member as a Licensed Vocational Nurse (LVN). Staff 1 was hired and worked as an LVN for over a year and a half without a valid nursing license. Review of the personnel file showed that Staff 1 only had a California ID and Social Security card, with no evidence of LVN license verification. The Director of Staff Development (DSD) confirmed that no license verification was conducted at the time of hire, and a subsequent check revealed that Staff 1 did not hold a valid LVN license. The facility's policy required license verification before employment, but this was not followed. During this period, Staff 1 administered controlled substances, including Norco, Tramadol, and Oxycodone, to multiple residents, including a resident with osteomyelitis. The Director of Nursing (DON) and DSD both acknowledged that allowing an unlicensed individual to function as an LVN posed significant risks, including improper medication administration and inaccurate documentation. The Administrator also confirmed that the facility did not follow its own policy and that hiring an unlicensed staff member placed all residents at high risk of harm.
Unlicensed Staff Administered Controlled Substances as LVN
Penalty
Summary
The facility failed to ensure that Staff 1, who was hired as a Licensed Vocational Nurse (LVN), met the required qualifications and held a valid professional LVN license in accordance with state laws. Staff 1 was employed and functioned as an LVN for over a year and a half without proper documentation or verification of a valid LVN license. The personnel file for Staff 1 contained only a California ID and Social Security card, and a copy of an LVN license belonging to an unidentified individual, which did not match Staff 1’s identification. The Director of Staff Development confirmed that Staff 1 was hired using another individual's LVN license and that no verification was conducted through the California Board of Vocational Nursing and Psychiatric Technicians system. During the period under review, Staff 1 administered controlled substances, including Norco, Oxycodone, Percocet, and Tramadol, to multiple residents with serious medical conditions such as osteomyelitis, fractures, and paraplegia. Medication Administration Records showed that Staff 1 administered these medications on numerous occasions to at least four residents, as well as to six additional residents. The facility’s policy required employment background screening and license verification, and stated that employees without a valid license should not be employed. The Administrator acknowledged that the policy was not followed, resulting in the employment of an unlicensed and unqualified individual who provided direct care and administered controlled substances to residents.
Failure to Monitor Behavior for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to conduct behavior monitoring for a resident who was prescribed the psychotropic medication escitalopram for major depressive disorder (MDD). The resident, who had moderate cognitive impairment and was dependent on staff for most activities of daily living, was admitted with a diagnosis of MDD and began receiving escitalopram as ordered by the physician for symptoms manifested by verbalizations of sadness. However, there were no physician orders or documentation in place to monitor the resident's behavior related to the use of this medication. Interviews with nursing staff and the Director of Nursing confirmed that behavior monitoring was required to track the frequency of the resident's symptoms and to assess the effectiveness of the psychotropic medication. Facility policy also required documentation of the rationale for use and monitoring for efficacy when medications were prescribed for behavioral symptoms. Despite these requirements, the resident did not have any active or discontinued orders for behavior monitoring since starting escitalopram, resulting in a lack of monitoring for the continued need or effectiveness of the medication.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Develop Care Plan for Major Depressive Disorder
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's diagnosis of major depressive disorder (MDD). The resident, who was admitted with MDD and had moderate cognitive impairment, was dependent on staff for all activities of daily living except eating and required substantial to maximal assistance for mobility. Despite the resident's diagnosis and ongoing treatment with antidepressant medication, there was no care plan in place to address her MDD, specifically lacking non-pharmacological interventions such as redirection, engagement in activities, or opportunities to discuss her feelings with staff. Interviews with facility staff, including an LVN and the Director of Nursing, confirmed that a care plan for MDD was not developed for the resident. Both staff members acknowledged the importance of having a care plan that included non-pharmacological interventions to address the resident's mental health needs. Review of facility policies indicated that comprehensive, person-centered care plans with measurable objectives were required for each resident, and that non-pharmacological interventions should be used to minimize reliance on psychotropic medications. The absence of such a care plan for the resident with MDD constituted the identified deficiency.
Failure to Ensure Nursing Staff Competency in Abuse Reporting Requirements
Penalty
Summary
Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 failed to demonstrate competency regarding the facility's abuse reporting policies. Both staff members had signed documents acknowledging their responsibilities as mandated reporters and had completed abuse training post-tests indicating they understood their roles. However, during interviews, both RN 1 and LVN 1 were unable to identify the facility's abuse coordinator and expressed uncertainty about their responsibilities as mandated reporters, despite having attended abuse prevention in-service training where reporting requirements were reviewed. The Director of Nursing (DON) confirmed that all staff were expected to be competent in implementing the facility's abuse policies and procedures, including knowing their mandated reporter responsibilities and the identity of the abuse coordinator. A review of the facility's Abuse Prevention Program policy indicated that staff training should include abuse prevention, identification, and reporting. The failure of RN 1 and LVN 1 to demonstrate this competency was identified through interviews and record reviews, indicating a gap between training provided and staff understanding or retention of critical abuse reporting procedures.
Failure to Change Security Code After Violent Incident
Penalty
Summary
The facility failed to change the security code for the gate and entrance door after an incident in which three unidentified individuals, allegedly known to a staff member, gained access to the premises and assaulted a Certified Nurse Assistant (CNA). Multiple staff interviews indicated that only facility staff should have knowledge of the gate code, but it was suspected that a staff member provided the code to unauthorized individuals. The incident was witnessed by other staff, who observed the perpetrators entering the facility's gated parking lot and subsequently assaulting the CNA, resulting in visible injuries such as a struck head, facial injuries, and the CNA falling to the ground. Despite the breach and the violent event, the facility did not change the access code following the incident. Staff expressed concerns about the ongoing safety risk due to the unchanged code, noting that this failure could allow unauthorized individuals to re-enter the premises. The facility's policy required investigation of such incidents and corrective action, but the report indicates that the code remained unchanged after the event, leaving staff and residents vulnerable.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Develop and Implement Individualized Care Plan for Resident Behavioral Issue
Penalty
Summary
The facility failed to implement an individualized, person-centered care plan with measurable objectives, timeframes, and interventions for a resident who exhibited problematic behavior. Specifically, after admission, a resident with diagnoses including encephalopathy, traumatic brain injury, and psychoactive substance use, and who was assessed as having severely impaired cognition and requiring moderate assistance with activities of daily living, was found in another resident's room going through personal belongings. This incident was documented in the progress notes. A review of the resident's care plans revealed that there was no care plan addressing the behavior of entering other residents' rooms and taking their belongings. During an interview, the DON confirmed that a care plan for this behavior had not been developed, despite facility policy requiring comprehensive care plans with goals, measurable objectives, and timetables to address identified needs. The lack of a care plan for this behavior was acknowledged as having the potential for repeat incidents and possible resident-to-resident altercations.
Failure to Document Physician Notification After Resident Change in Condition
Penalty
Summary
The facility failed to maintain proper clinical documentation for one resident by not recording the notification of a change in condition to the attending physician and psychiatrist. Specifically, a resident with a history of traumatic brain injury, epilepsy, alcohol abuse, and major depressive disorder exhibited verbal and physical aggression, which was documented in the progress notes. However, there was no documentation that this incident was reported to the resident's physician or psychiatrist as required. During an interview and record review, the DON confirmed that although the incident was verbally communicated to the primary care physician and psychiatrist, it was not documented in the resident's clinical record. The facility's policy requires that changes in a resident's medical or mental condition be reported and documented. The lack of documentation could disrupt the chain of communication among staff and providers.
Failure to Provide Dietary Menus to Bedbound Residents
Penalty
Summary
The facility failed to ensure that two residents who were unable to get out of bed without staff assistance were provided with the daily dietary menu, resulting in these residents not being able to choose their food preferences. Observations and interviews revealed that neither resident had access to the menu in their rooms, and both reported not knowing what they would be served for meals until the food was brought to them. They also stated they were not informed about alternative food options and, in some cases, would not eat if they did not like the food provided. Resident 1 was totally dependent on staff for activities of daily living due to conditions such as intervertebral disc degeneration, diabetes mellitus, and sacroiliitis, but had no cognitive impairment and was able to make medical decisions. Resident 3 required substantial assistance with ADLs due to joint replacement surgery, unsteady gait, and generalized weakness, and also had the capacity to understand and make decisions. Both residents' physician orders specified particular dietary needs, but neither was given the opportunity to review or select meal options in advance. Staff interviews confirmed that menus were not provided in the residents' rooms and that some staff, including CNAs, were unaware of the daily menu. The dietary supervisor and LVN acknowledged that residents have the right to know their meal options and be informed of alternatives. The DON stated that menus were posted only in common areas, not in residents' rooms, and that residents who could not access these areas would only receive menu information if they asked. Facility policy required that residents be treated with respect and dignity and be assisted in exercising their rights, but this was not followed in the cases of these two residents.
Medication Error: Unattended Topical Medication at Bedside
Penalty
Summary
A medication error occurred when a medication cup containing zinc oxide cream was left unattended on a resident's bedside table. The resident, who had moderate cognitive impairment and required substantial assistance with activities of daily living, was unaware that the cream was present. The zinc oxide cream was prescribed to be applied to the resident's sacral coccyx area for skin maintenance. The nurse responsible for administering the medication stated she had prepared the cream but left it at the bedside while waiting for a CNA to finish cleaning the resident, acknowledging that it was not acceptable to leave the medication unattended. Facility policy required all medications to be stored securely and to be inaccessible to residents or others passing by. Both the nurse and the Director of Nursing confirmed that medications should never be left unattended, as this could result in accidental ingestion or use by residents. The facility's policies on medication storage and administration emphasized the importance of safe and timely administration, with medications only visible to the personnel administering them and not accessible to residents.
Failure to Properly Label and Store Refrigerated Food Items
Penalty
Summary
Surveyors observed that the facility failed to store food in a sanitary manner, as required by professional standards and facility policy. Specifically, several thawing food items in the kitchen refrigerator were not labeled with the date and time when thawing began, including a box of fully cooked pork sausage patties, a box of oven roasted sliced turkey breast, and a container of packaged chicken. Additionally, opened items in the refrigerator, such as sliced pasteurized American Swiss cheese, fully cooked pork sausage patties, and minced garlic, were not properly sealed and lacked both opened and discard dates. The Dietary Supervisor confirmed that these practices could result in staff being unaware of how long food items had been thawed or opened, which could lead to food spoilage. A review of the facility's policies and procedures revealed requirements for all refrigerated and frozen foods to be covered, labeled, and dated, including the use of received, opened, and use-by dates. Policies also specified that thawing meats should be labeled with pull and use-by dates, and that uncooked thawed meat should be used within a specified timeframe. The observed deficiencies indicated that these policies were not consistently followed, as multiple food items were found without proper labeling or sealing during the survey.
Failure to Complete Leave of Absence Documentation for Resident on Pass
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a required Release of Responsibility for Leave of Absence Form was completed for a resident before allowing the resident to leave the premises on pass. The resident, who had a history of cerebral infarct and alcohol dependence, was permitted to leave the facility with his brother after an order was obtained for a pass not to exceed four hours. However, the resident did not return as expected, and the facility lacked documentation regarding his destination, contact information, and expected return time because the required form was not filled out. Staff interviews and record reviews confirmed that the established procedure required residents or their representatives to complete a form indicating the date and time of departure, expected return, destination, and contact information. In this case, staff acknowledged that the form was not completed, which resulted in the facility not having essential information to locate the resident when he did not return as planned. The resident later reported that he decided not to return to the facility and went home instead, without notifying the staff.
Failure to Verify RN License Status and Ensure Competency Compliance
Penalty
Summary
The facility failed to ensure that licensed nurses, specifically a registered nurse (RN), had the appropriate competencies and skill sets to care for residents. The facility did not check and verify the RN's license status, which was on probation with specific restrictions, including limited work hours, required supervision, and mandatory audits and evaluations. The Director of Staff Development (DSD) and Director of Nursing (DON) were unaware of the RN's probationary status and the associated stipulations. The RN was allowed to work overtime and without the required supervision, contrary to the conditions set by the licensing board. Additionally, the facility did not maintain documentation of completed nursing skills and competencies for the RN, nor did it monitor or audit the RN's documentation and work performance as required. Interviews with facility staff revealed a lack of awareness and oversight regarding the RN's probationary status and the necessary compliance measures. The DSD could not recall when the RN's license was last checked, and the DON was not informed about the probation. The facility's policy required verification and documentation of licensure, but these procedures were not followed. As a result, there was a potential for all 113 residents in the facility to not receive proper and safe care due to the lack of verification and monitoring of the RN's qualifications and compliance with probationary requirements.
Inaccurate Documentation of Change of Condition and Vital Signs
Penalty
Summary
The facility failed to maintain accurate and timely clinical records for one resident by not ensuring that the documented times for vital signs and the change of condition accurately reflected when these events occurred. Specifically, the resident, who had a history of COPD, paroxysmal atrial fibrillation, and heart failure, experienced chest pain and was administered nitroglycerin as ordered. However, the times recorded for the onset of chest pain, administration of medication, and the taking of vital signs were inconsistent and did not match the actual sequence of events as described by staff interviews and record reviews. Documentation in the resident's medical record showed discrepancies, such as the physician being notified before the documented onset of chest pain and vital signs being recorded at times that did not correspond with the actual events. The facility's policy required that documentation be objective, complete, and accurate, including care-specific details and assessment data. The Director of Nursing and Quality Assurance Nurse both acknowledged that the documentation was inaccurate and did not provide a reliable timeline of the resident's change of condition and interventions.
Failure to Address Room Change Request
Penalty
Summary
The facility failed to accommodate a resident's request to change rooms, resulting in emotional distress for the resident. The resident, who was admitted with diagnoses including muscle weakness and major depressive disorder, expressed feelings of anger and hurt due to interactions with her roommate. Despite being able to communicate effectively, the resident's request to move was not addressed promptly. The resident reported her concerns to a CNA and an LVN, but both staff members did not take immediate action to facilitate the room change. The CNA advised the resident to ignore her roommate, while the LVN delayed reporting the request due to returning from lunch. The facility's policy on room changes states that changes should be made upon a resident's request. However, the Social Services Director and the CNA were aware that the resident's former room was occupied, and the CNA mentioned that the room was being used for isolation. Despite this, there was no indication that alternative solutions were explored to address the resident's request. The lack of timely action and communication among staff members contributed to the resident's continued emotional distress.
Failure to Develop Individualized Care Plan for Resident's Skin Condition
Penalty
Summary
The facility failed to develop an individualized care plan for a resident who experienced skin itchiness and swelling in both hands. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted with diagnoses of muscle weakness and hyperlipidemia, had a history of fluctuating capacity to understand and make decisions. Despite these conditions, the facility did not create a care plan to address the resident's persistent skin issues, which included severe itching, redness, and pain, as documented in multiple Change of Condition reports. The lack of a care plan resulted in the resident's skin condition worsening, leading to multiple hospitalizations. During an interview, an LVN acknowledged that no care plan was in place to manage the resident's skin problems, which could have provided necessary interventions and monitoring. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's needs, but this was not implemented for the resident in question.
Failure to Document and Follow Physician Orders Leads to Inadequate Care
Penalty
Summary
The facility failed to document a Change of Condition (COC) assessment for a resident who was sent to a General Acute Care Hospital (GACH) due to shortness of breath. This lack of documentation was noted during a review of the resident's progress notes, which did not indicate the reasons for the transfer to the hospital. Additionally, the facility did not create a non-pressure skin assessment form as required by their policy, which would have helped in monitoring and managing the resident's skin condition. The facility also failed to carry out a physician's order for a dermatology consult for the resident, who had been experiencing severe skin issues, including itching, redness, and pain. Despite multiple hospitalizations and recommendations for follow-up with a dermatologist, the resident's clinical records did not show any attempt to schedule the necessary appointment. This oversight contributed to the worsening of the resident's skin condition, as proper treatment and diagnosis were delayed. Interviews with staff and family members revealed that the resident felt neglected due to the lack of care for her skin condition. The resident's family member had to request hospital transfers due to the worsening condition, and the resident expressed feelings of sadness and neglect. The facility's failure to create a care plan for the resident's skin condition and to follow up on physician orders resulted in inadequate care and multiple hospitalizations.
Failure to Administer Scheduled Medications
Penalty
Summary
The facility failed to ensure that a resident was administered scheduled medications, specifically Losartan for hypertension and Aspirin for CVA prophylaxis, on February 21, 2025. The resident, who was admitted with diagnoses of essential hypertension and hyperlipidemia, had a care plan indicating the need for these medications. On the day in question, the Medication Administration Record (MAR) noted that the resident was away from the facility, and the medications were not administered. However, the resident reported that the Licensed Vocational Nurse (LVN) did not provide the medications before the resident left for an appointment, despite the resident's request and concern about her blood pressure. Interviews with the LVNs involved revealed that the assigned nurse, LVN 4, documented that the resident was not available at the time of medication administration. LVN 4 admitted to not offering the medications because the resident was busy with a Certified Nurse Assistant and was on the bedside commode. The facility's policy requires medications to be administered within one hour of their prescribed time, which was not adhered to in this instance. This oversight had the potential to cause significant health complications for the resident.
Facility Fails to Maintain Safe and Sanitary Restrooms
Penalty
Summary
The facility failed to provide a safe and comfortable environment for two residents by not maintaining the restrooms in good repair. Resident 4, who was admitted with conditions including hypertension, muscle weakness, urinary tract infection, and a history of falls, expressed discomfort and fear of infection due to the poor state of Restroom A. The restroom had broken baseboards, which made the area look old and unsanitary, potentially allowing bugs to enter. This situation led Resident 4 to avoid using the restroom, opting instead for a commode. Resident 5, diagnosed with multiple sclerosis and muscle weakness, also faced issues with the facility's restrooms. The family member of Resident 5 reported that Restroom B had a hole in the wall and deteriorating floors, while Restroom A had similar issues with the baseboards. The Maintenance Supervisor confirmed these observations, noting wet and corroded door frames, peeling paint, and chipped wood. Additionally, CNA 5 highlighted the risk of tripping due to cracked and uneven floors in Restroom B. The facility's policy on providing a homelike environment was not upheld, as the restrooms were neither safe nor sanitary.
Failure to Prevent Elopement and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure the safety of several residents, particularly Resident 118, who was assessed as high risk for wandering and elopement. Despite this assessment, Resident 118 eloped from the facility twice, on two separate occasions. The facility did not implement a person-centered care plan with measurable interventions after the first elopement, nor did they conduct a 72-hour monitoring upon readmission to assess for exit-seeking behaviors. Additionally, Resident 118 was placed in a room near the lobby exit, which was inappropriate given his high risk for elopement. The facility also failed to notify the State Agency following an incident involving Resident 117, who trespassed onto the facility premises with a large knife. This incident posed an immediate risk to the welfare and safety of the facility's residents and staff. Furthermore, the facility did not ensure that Resident 319's and Resident 55's lighters were securely stored and inaccessible to other residents who were identified as unsafe to independently use or keep a lighter in their possession. Additionally, the facility did not place a fall mat at Resident 99's bedside, increasing the risk of injury from a fall. These deficiencies collectively placed all facility residents at risk for avoidable physical and psychosocial harm, including potential burn-related injuries from unsupervised use of lighters and physical injury from falls.
Removal Plan
- A facility-wide assessment was conducted by the Director of Nursing, Director of Staff Development, Minimum Data Set Nurse, and the Quality Assurance Nurse to reevaluate all in-house residents. The Medical Records Director conducted an audit to identify other residents who were at high risk for elopement. Three residents were identified at high risk for elopement.
- An IDT meeting was conducted for Residents 48, 60, and 63 to address their high risk for elopement score.
- Residents 48, 60, and 63's care plans were updated by the DON to address their elopement and wandering risk with goals and interventions.
- The ADM, DON, and DSD developed a visual aide and process to assist in clearly identifying all residents who were high risk for elopement and is routinely accessed by staff. The color blue was adopted as an elopement risk identifier.
- The ADM updated the facility P&P titled, Safety and Supervision of Residents to include executing and implementing interventions identifiers. The ADM updated the P&P titled, Wandering, Unsafe Resident to include specific actions for high risk residents.
- The ADM conducted an immediate Quality Assurance Meeting to include a report that outlined the updated P&Ps titled, Safety and Supervision of Residents and Wandering, Unsafe Resident.
- The DON and DSD started an immediate in-service with all staff regarding the updated P&Ps titled, Safety and Supervision of Residents and Wandering, Unsafe Resident, how to provide safety and supervision to residents, identification of residents who were high risk for elopement, unsafe wandering behavior, color code identifying elopement risk residents, and the location of COC and department binders.
- The DSD would provide initial education during the employee's on-boarding orientation, thereafter the DSD and/or the DON would provide the continued in-serviced to all facility staff at least quarterly and as needed.
- Upon completion of any resident's IDT or COC, where the outcome results in the resident being at risk for elopement, the DON, DSD, or ADM would assess the resident's room assignment.
Unsafe Discharge of Residents Without Consent
Penalty
Summary
The facility failed to safely discharge three residents, identified as Residents 117, 320, and 321, without their knowledge, request, or consent. Resident 117 was discharged after not returning from an approved out-on-pass (OOP) leave within the four-hour limit. Despite having the capacity to make decisions and no expressed desire to leave, the facility discharged him against medical advice (AMA) without confirming his whereabouts or safety. This led to a dangerous situation when Resident 117 returned to the facility brandishing a knife, indicating the discharge was not safe. Resident 320 was similarly discharged AMA after not returning from an OOP leave. The facility had no contact information for him and did not confirm his safety or intent to be discharged. Despite his refusal to be discharged home and ongoing therapy, the facility proceeded with the discharge without explaining the risks or obtaining an AMA acknowledgment. His whereabouts remained unknown at the time of the report. Resident 321 was discharged AMA after leaving the facility on an OOP leave and not returning as expected. Although he informed the facility of his intent to return, the facility discharged him without confirming his safety or obtaining an AMA acknowledgment. He later returned to the facility in poor condition, indicating he had been living on the street. The facility's policy required a resident to request an immediate discharge and sign a release of responsibility form, which was not followed in these cases.
Failure to Provide Advance Notice of Discharge
Penalty
Summary
The facility failed to provide advance notice of discharge to three residents, which led to their discharge against medical advice (AMA) without proper communication or preparation. Resident 117, who had a broken right thigh bone and major depressive disorder, was discharged AMA after not returning from an approved out-on-pass (OOP) leave. The facility did not confirm with Resident 117 his intention to be discharged, nor did they communicate the discharge information to him. Upon his return, he was informed of his discharge and subsequently removed by law enforcement. Resident 320, admitted with generalized muscle weakness and type 2 diabetes, was also discharged AMA after not returning from an OOP leave. The facility had no contact information for Resident 320 and did not confirm his intention to be discharged. The discharge was executed without explaining the risks of leaving AMA, and the resident's whereabouts remained unknown. Resident 321, with peripheral vascular disease and muscle weakness, left the facility OOP and informed staff of his intent to return. However, he was discharged AMA without expressing a desire to leave the facility permanently. The facility did not contact Resident 321 after his last communication, and he returned a month later to collect his belongings. The facility's policy required a resident to request an immediate discharge and sign a release of responsibility form, which was not followed in these cases.
Failure to Conduct Competency Evaluations for Staff
Penalty
Summary
The facility failed to conduct competency skills evaluations for five sampled employees, including three Certified Nursing Assistants (CNAs) and two licensed nurses, upon hire and annually as required. Specifically, CNA 1 and CNA 4 did not have any competency skills evaluations on file from their hire dates in 2019 and 2022, respectively, nor were there annual evaluations conducted. CNA 2, hired in 2017, had not received an annual competency evaluation since 2019. The Director of Staff Development (DSD) acknowledged the lack of evaluations and emphasized their importance in assessing employee performance and identifying areas for improvement to ensure quality resident care. Additionally, the facility did not conduct competency skills evaluations for RN 2 and LVN 1 upon their hire dates in 2024. The Director of Nursing (DON) confirmed the absence of these evaluations and highlighted their role in determining the necessary skills and training for licensed staff to provide adequate care and treatments for residents. The facility's policies and procedures outlined the responsibilities of the DSD and DON in conducting and maintaining documentation of staff competency evaluations, which were not adhered to in these cases.
Infection Control Lapses in Water Pitcher Handling and IV Dressing Changes
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations and interviews. Five dirty water pitchers were found stored on top of the ice machine in the ice machine room, which is designated for clean items only. The Assistant Dietary Supervisor (ADS) confirmed that dirty pitchers should not be placed on the ice machine and that the pitchers were color-coded to distinguish between clean and dirty ones. However, the presence of blue-colored pitchers, which were supposed to be dirty, in the ice machine room indicated a lapse in following the protocol. Further observations revealed that blue and pink water pitchers were mixed together on the storage rack, contrary to the protocol that only clean pink pitchers should be present. Interviews with staff, including a Dietary Aide (DA 1) and a Certified Nursing Assistant (CNA 5), highlighted confusion and non-compliance with the color-coding system. The Director of Staff Development (DSD) and the Infection Prevention Nurse (IPN) acknowledged the lack of a formal policy for the use and cleaning of water pitchers, which contributed to the improper handling and potential cross-contamination. Additionally, the facility failed to monitor and change the IV dressing for Resident 115, who had an IV inserted on 1/7/2025. The dressing had not been changed since insertion, despite the facility's policy requiring changes every 5 to 7 days. Interviews with Resident 115 and Registered Nurse (RN) 1 confirmed the oversight, with the resident expressing concern about the unchanged dressing. The facility's failure to adhere to its own policy increased the risk of infection at the IV site for Resident 115, who had a history of abscess and diabetes mellitus, conditions that could complicate wound healing.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to significant deficiencies in care. Resident 118, who had a history of Alzheimer's disease and was at high risk for wandering and elopement, eloped from the facility twice. Despite being identified as high risk, there was no care plan addressing these risks, leaving staff without guidance on how to manage the resident's behavior. This lack of planning resulted in the resident's second elopement, which was not prevented due to the absence of a structured care plan. Additionally, the facility did not create care plans for other residents at high risk for wandering and elopement, such as Residents 48, 63, and 60. These residents had varying degrees of cognitive impairment and mobility issues, yet their care plans did not reflect their high-risk status. The absence of specific interventions and monitoring plans left these residents vulnerable to potential elopement and wandering incidents, as staff were not adequately informed or prepared to address their needs. The facility also failed to address other critical care needs, such as the use of temazepam for Resident 9, the use of bed rails for Residents 75, 42, and 71, and the provision of a fall mat for Resident 99. Resident 11 did not receive the prescribed Magic Cup and modified texture diet, which were essential for their nutritional care plan. These omissions in care planning and implementation resulted in inadequate monitoring and potential harm to the residents, as staff were not provided with the necessary guidance to ensure their safety and well-being.
Failure to Follow Menu and Diet Consistency Guidelines
Penalty
Summary
The facility failed to adhere to the standardized recipes for the lunch menu on two consecutive days, resulting in the substitution of food items without the registered dietician's (RD) approval. On the first day, the facility served mashed potatoes instead of buttered new potatoes and vanilla pudding instead of chocolate yogurt mousse due to unavailable ingredients. The Assistant Dietary Supervisor (ADS) acknowledged the substitutions and noted that the changes were documented but not yet approved by the RD. Additionally, a resident complained about the breakfast menu not being followed, as waffles and grits were replaced with omelets and toast due to missing ingredients. The facility also failed to provide the correct food textures for residents on modified diets. Residents on a mechanical soft diet received shredded pork pot roast instead of ground, and those on a pureed diet received a bread slurry that was thin and lumpy instead of a smooth puree. The per diem cook admitted to the error, acknowledging that the shredded pork could pose a choking risk. The ADS and Dietary Supervisor (DS) confirmed that the pork should have been ground, and the pureed bread should have been of a pudding-like consistency. Interviews with the RD and the Administrator revealed a lack of communication regarding the missing ingredients and menu changes. The RD was unaware of the substitutions and the delivery issues, while the Administrator acknowledged the potential for resident dissatisfaction due to unmet menu expectations. The facility's policies and procedures for menu preparation and modified diets were not followed, contributing to the deficiencies observed.
Food Temperature and Flavor Deficiency
Penalty
Summary
The facility failed to ensure that food was prepared and served at appetizing temperatures, affecting 115 out of 120 residents who received food from the kitchen. During an initial facility tour, complaints about the temperature and flavor of food were identified, and these issues were also discussed during a resident council meeting. Observations in the kitchen revealed that the facility did not serve the menu items as planned due to stock issues, and the food temperatures were recorded as being higher than necessary, which could lead to a drop in temperature by the time the food was served. Resident 70 specifically complained about the cold temperature of the pork chops served for lunch. A test tray conducted later showed that the food temperatures varied from warm to lukewarm, with some items being below 100 degrees Fahrenheit. The Dietary Supervisor acknowledged that the trays sat in the cart for too long, causing a temperature drop, and confirmed that the food should have been served at higher temperatures. This deficiency had the potential to result in meal dissatisfaction and decreased food intake among residents.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. Nutritional supplements that required monitoring for thaw dates were not properly tracked, leading to potential use of expired products. Additionally, unpasteurized shell eggs were stored in the facility's walk-in refrigerator and used to prepare fried eggs for residents, contrary to the facility's policy of using only pasteurized eggs for dishes that are not thoroughly cooked. Other food items, such as breakfast pork sausage and turkey broth, were stored without proper date labeling, exceeding their safe storage periods. The kitchen equipment and work areas were not maintained in a clean manner, with dried food debris and stains observed on the oven, range, and steam table. The cleaning schedule was not adhered to, as the cook responsible for daily cleaning was absent, and the cleaning log was not updated. This lack of cleanliness posed a risk of pest infestation and microorganism growth, which could lead to foodborne illnesses among residents. Resident food brought from outside the facility was stored without proper date labeling in the resident refrigerator, with some items exceeding their use-by dates. The dietary staff was responsible for monitoring and discarding expired food, but this was not consistently done, increasing the risk of residents consuming spoiled food. These practices had the potential to result in harmful bacteria growth and cross-contamination, affecting the health of the residents who consumed food from the facility.
Failure to Honor Resident Rights and Provide Timely Assistance
Penalty
Summary
The facility failed to honor the rights of two residents, leading to deficiencies in their care. Resident 75, who was admitted with conditions such as dysphagia, muscle weakness, and hypertension, requested an extra blanket and clean bed linens due to feeling cold and uncomfortable. Despite being cognitively intact and able to make decisions, Resident 75's requests were denied by CNA 3, who stated that it was not yet nighttime and that the facility policy allowed only one bed linen change per day. This refusal left Resident 75 feeling disrespected and upset. Resident 42, diagnosed with schizophrenia, bipolar disorder, major depressive disorder, muscle weakness, and dysphagia, experienced a similar neglect of rights. With moderately impaired cognitive skills, Resident 42 required assistance for activities of daily living. When Resident 42 activated the call light to request a wheelchair or walker to go outside, CNA 3 turned off the call light without entering the room or addressing the resident's needs. This oversight was due to CNA 3's assumption that the call light was activated accidentally and her haste, resulting in Resident 42 being unable to access the patio. The facility's policies on resident rights and call light response were not adhered to, as evidenced by the actions of CNA 3. The Director of Staff Development confirmed that CNAs are expected to respond to call lights promptly and provide necessary care, emphasizing the importance of treating residents with respect and dignity. The facility's failure to comply with these policies resulted in the violation of the residents' rights to dignity and self-determination.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident or their responsible party before initiating treatment with Cymbalta, a psychotropic medication. This deficiency was identified during a review of the resident's records, which showed that the medication was prescribed for polyneuropathy unspecified. Despite the resident having the capacity to understand and make decisions, there was no documentation of informed consent being obtained prior to the medication's initiation. The Director of Nursing acknowledged the oversight, attributing it to staff not being aware that informed consent was necessary even when the medication was not used for behavioral management. The facility's policy and procedure on informed consent clearly stated that residents have the right to consent to or refuse any treatment, including the use of psychotropic drugs. The policy required verification that informed consent was given before initiating such medications. The lack of informed consent documentation meant that the resident or their representative was not able to exercise their right to opt out of treatment with Cymbalta, potentially exposing the resident to adverse effects without their informed agreement.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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