California Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Van Nuys, California.
- Location
- 6700 Sepulveda Blvd., Van Nuys, California 91411
- CMS Provider Number
- 056149
- Inspections on file
- 70
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at California Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Protect Resident PHI: A diet type report containing residents’ names, room numbers, diet orders, and allergies was observed discarded in a trash can instead of being shredded. The DS confirmed the report was improperly thrown away and stated it was a HIPAA violation because it contained protected information.
A facility failed to develop and implement person-centered care plan interventions for multiple residents. Three residents with restraint orders that included holiday breaks had no specific monitoring interventions in their care plans when the restraints were removed, two residents on oxygen had care plan interventions that were not carried out as written, one resident on apixaban had no documented monitoring for bleeding signs and symptoms, and one cognitively intact resident who refused the flu vaccine had no care plan addressing the refusal.
Respiratory Care Deficiency: Oxygen Tubing Not Dated and Ordered Oxygen Not Provided. Two residents receiving O2 therapy had care plan interventions for weekly tubing changes and dating of equipment, but staff did not date the tubing for either resident. One resident was observed on O2 via TBar/Tmask with tubing not dated, and another resident with an order for continuous humidified O2 at 5 L/min was found in bed without O2 connected while the concentrator was running. RT, CNA, ADON, and DON interviews confirmed the tubing was not dated and that the ordered O2 was not in place.
Inaccurate Daily Nurse Staffing Postings: The facility failed to keep daily nurse staffing postings current and accurate for the SNF and Subacute unit. A framed staffing form in the SNF was outdated and still reflected prior information, the facility did not post staffing information for two days in the SNF area, and the postings did not include the actual resident census or actual hours worked by RN, LVN, and CNA staff. In the Subacute unit, the section labeled Actual Hours Worked contained projected hours instead of actual hours, and the forms were completed in pencil rather than black ink, contrary to policy.
A resident’s lidocaine patch was found still in place beyond the ordered 12-hour period, and two other residents missed ordered medications because glipizide, menthol-methyl salicylate cream, and oyster shell calcium were not available in the facility at the scheduled times. An LVN administered other ordered meds but did not give the missing doses, and the DON acknowledged the facility had not maintained delivery or availability of the medications as prescribed.
Medication error rate exceeded allowable threshold. Surveyors found 4 medication errors out of 26 opportunities, including omitted doses of sevelamer, oyster shell calcium, glipizide, and menthol-methyl salicylate cream. An LVN administered some ordered meds but failed to give the omitted doses, and the DON confirmed the omissions were medication errors tied to unavailable meds and failure to follow ordered administration.
Significant medication errors occurred when an LPN failed to administer a resident’s scheduled glipizide because the medication was not available in the cart or facility. The resident, who had DM Type 2, had multiple missed doses documented on the MAR, and the DON and RN confirmed the omissions were significant medication errors.
An LVN and the DON were observed with two medication carts containing medication handling errors. A levalbuterol inhalation solution pouch for one resident was left undated after opening, and an open latanoprost eye drop bottle for another resident remained in use after its expiration period. Facility policy and manufacturer instructions required multi-dose products to be dated when opened and outdated medications removed from stock.
Food items were not consistently held or served at palatable temperatures, and vegetables were overcooked and discolored. Cold trayline items such as pudding, fruit cup, spring fruit crisp, and milk were observed above cold-holding temperatures, while a breakfast test tray showed sausage, waffles, oatmeal, and milk at temperatures that were not hot enough. Residents reported cold meals and delayed meal service, and the DS and RD acknowledged the temperature and timing problems.
Improper Texture of Pureed Foods: Puree items on the trayline were observed to be flat, spread out, and watery rather than holding their shape. No spoon tilt test or fork pressure test was observed during service, and the DS and RD stated the food did not meet IDDSI Level 4 expectations for residents with swallowing difficulty.
Late Meal Service: Meal service was delayed beyond the posted schedule, with lunch and breakfast traylines running late and trays not fully passed until well after the expected times. Two residents reported that lunch arrived nearly 2:00 p.m. and that meals had been arriving late recently. The DS said the delay was due to extra resident requests, and the RD noted meals should come on time to maintain resident satisfaction and food palatability.
Kitchen sanitation, hand hygiene, and food storage failures were observed during food prep, dishwashing, and trayline activities. A drink was stored in the pitcher area, staff did not wash hands after sneezing, touching hair or a mask, or moving from dirty to clean tasks, and another staff member handled food after touching a trash can lid without handwashing. Refrigerator/freezer logs were incomplete, a freezer lacked a thermometer, multiple storage and prep surfaces had dirt or spills, dented cans were mixed with intact cans, trays and pans were not properly air-dried, and QUAT sanitizer use and testing did not follow required contact time and temperature procedures.
Improper garbage handling was observed when a trash container in the food prep area was left uncovered while not in use, and the Dietary Supervisor stated it should have been kept closed to prevent cross-contamination. Surveyors also observed dark liquid spills around the dumpster, and the DS and MS stated the area should be kept clean and free of spills and trash; the facility policy required trash bins to be covered and the surrounding area kept clean.
The facility inaccurately documented a resident’s diagnoses and POLST, failed to provide a signed consent for lower side rails for another resident despite an order for bilateral side rails, and charted multiple doses of menthol-methyl salicylate cream as given on a MAR even though the medication was not available in the facility. Staff and the DON acknowledged the missing diagnosis entry, the absent lower side rail consent, and the inaccurate MAR documentation.
Delayed Influenza Vaccination and Documentation: The IPN delayed giving the 2025/2026 flu vaccine to four residents until late in the season, even though consent had been obtained and there was no vaccine shortage. One resident’s vaccination was also not entered in the EMR Immunization Details. The residents had significant medical conditions including respiratory failure, COPD, ventilator dependence, and hydrocephalus, and several were dependent on staff for all ADLs.
Failure to maintain resident dignity and privacy occurred when an IPN entered a resident’s room without knocking or asking permission, despite the resident’s dementia, trach, ventilator dependence, and total ADL dependence. In a separate event, another resident with a Foley catheter had the drainage bag visible to public view instead of being covered with a dignity bag. Staff acknowledged that residents’ privacy should be protected and that catheter bags should be covered.
A resident with dementia, diabetes, and HTN had bilateral upper and lower half side rails up and locked in bed, but staff could only locate informed consent for the upper side rails. RN, ADON, and DON all confirmed that no signed consent could be found for the lower side rails, despite the facility policy requiring informed consent from the resident or POA before using side rails.
Advance Directive Not Clarified With Healthcare Agent: A resident with severe cognitive impairment, stroke-related diagnoses, and extensive ADL dependence had orders and a POLST indicating attempt resuscitation and full treatment, while the advance directive stated the resident did not want to prolong life. The SSD stated the POLST should have reflected selective treatment and that the family should have been contacted to clarify the resident’s wishes.
Two residents were found in rooms that were not maintained in a safe, clean, and homelike manner. One resident, who had the capacity to make decisions and needed supervision for hygiene-related ADLs, did not have a trash bin in his room and was observed placing trash in a bin labeled for a urinal. Another resident, who was dependent on staff for all ADLs and was minimally alert and non-communicative, had a floor mat coming apart at the edges, trash and a towel under the bed, and a dried dark red substance on the bed frame that remained on follow-up observation.
Failure to Follow Restraint Holiday Order: A resident with severe cognitive impairment and diagnoses including acute respiratory failure with hypoxia, tracheostomy, gastrostomy, and traumatic subdural hemorrhage was observed wearing a left-hand mitten restraint despite an order requiring removal on restraint holidays. The order also required the mitten to be released every 2 hours for circulation and skin checks, but the ADON stated the holiday removal order was not followed.
Incomplete Admission Comprehensive Assessment: A resident with CVA, nontraumatic subarachnoid hemorrhage, and HTN had an admission comprehensive assessment that remained in progress and was not completed by the required deadline. The MDS showed severely impaired cognitive skills and extensive assistance needs for ADLs, and the AMDS confirmed the assessment could not be closed because four areas, including Social Services and Dietary, were still incomplete.
Delayed MDS Transmission for Two Residents: The facility failed to timely complete and transmit discharge MDS assessments for two residents. One resident with DM, impaired cognition, and a planned discharge had a discharge MDS left in progress past the required timeframe, and another resident with chronic respiratory failure with hypoxia, severe cognitive impairment, and an unplanned hospital transfer also had a late discharge MDS. The MDSN stated both assessments should have been completed within 14 days, and the DON stated the MDSN should have followed MDS guidelines.
A resident with a right temple skin condition had a biopsy recommended by dermatology but refused it twice, and the LPN did not notify the primary physician of either refusal. The resident’s topical treatment and dressing order then expired, and there were no current orders for ongoing care of the right temple sore; the LPN continued care based on the wound being dry or per the resident’s request rather than having active orders. The ADON stated the physician should have been notified and new orders obtained.
Improper Use of Low Air Loss Mattresses for Two Residents: A resident with existing pressure ulcers had an LALM left on a firm setting instead of the ordered setting, and another resident’s LALM was found turned off during repeated observations. Both residents had severe cognitive impairment and were dependent for ADLs, and both had physician orders and care plans directing use of the LALM for wound care, skin maintenance, and pressure ulcer prevention.
A facility failed to keep the resident environment free of accident hazards for two residents with fall precautions in place. One resident with severe cognitive impairment and high fall risk had a floor mat placed away from the bed, with a waste container and medical device pole on top of it, while staff stated the mat should be next to the bed and clear of items. Another resident with a history of falling and total dependence had an order for a floor mat, but the mat was missing from one side of the bed when observed, and the ADON and DON confirmed it should have been there.
A resident with dementia, a tracheostomy, and ventilator dependence was observed in bed with indwelling catheter tubing hanging below the bed in a large dependent loop. The tubing contained urine with sediment that back flowed toward the drainage port. The IPN stated the tubing should be straight for proper drainage, and the ADON stated staff should ensure catheter tubing remains straight and not coiled or looped to prevent UTIs.
GT Not Flushed Before Med Pass: An LPN was observed preparing to give crushed meds through a resident’s GT without first flushing the tube with water. The surveyor stopped the med pass before any meds were given, and both the LPN and DON confirmed the GT had not been flushed as required by the resident’s order and facility policy.
A resident with ESRD and dialysis dependence had blank pre- and post-dialysis weight fields on the Dialysis Communication Record. The resident’s care plan called for use of post-dialysis dry weights, and both the LVN and RN confirmed the weights were missing. Staff stated the dialysis center should be contacted for the missing weights, but nursing notes did not show that this occurred, and the facility policy required the dialysis facility nurse to complete the record and return it for the post-dialysis assessment.
A resident with intracranial hemorrhage, respiratory failure, and hypertensive emergency was observed with all four bed rails raised, even though the physician's order and informed consent only addressed bilateral upper half side rails. Staff interviews confirmed the resident was being positioned with four side rails without a specific order or consent for that setup, and the facility policy required informed consent before bed rail use.
Failure to Monitor and Document Apixaban Side Effects: A resident with severe cognitive impairment, chronic respiratory failure, hypertension, and functional quadriplegia received apixaban 2.5 mg BID for DVT prophylaxis. Review of the MAR and EMAR showed the medication was administered, but there was no documented monitoring for anticoagulant side effects such as bleeding. The ADON and DON both stated apixaban can cause serious bleeding and that no evidence of monitoring or assessment was found.
A resident with documented capacity to make decisions signed an arbitration agreement, but staff did not ensure it was explained in a way he understood. During interviews, the resident showed confusion about the process, stated he did not understand the agreement, and said he signed it because staff wanted him to. The AA said she explains arbitration in person if a resident is alert, while the SSD and RN noted periods of confusion and the resident made statements suggesting impaired understanding.
A resident placed trash into a bin labeled for urinals that already contained a urinal, and staff confirmed the trash should have been kept in a separate bin. In a shared room under contact precautions for CRPA, a visitor entered without a gown or gloves even though a Stop—Contact Precaution sign was posted; a CNA acknowledged the visitor was not wearing PPE and did not intervene. The residents in the room had severe cognitive impairment, were dependent for ADLs, and had orders and care plans for contact isolation.
A resident with impaired cognition, multiple medical diagnoses, and dependence for several ADLs had a physician order for RNA sit-to-stand treatment with a platform walker and two-person assist five times per week as tolerated. Over a period of time, the resident repeatedly refused this restorative treatment, and staff acknowledged that such refusals should be reported, explained to the resident, and addressed through the care planning process. Despite this, no specific care plan or alternative program was developed or added to the resident’s comprehensive care plan to address the ongoing refusals, contrary to facility policies requiring person-centered care plans that include services not provided due to resident refusal and documentation by the IDT of refusals and interventions tried.
A resident lacking decision-making capacity had extensive PHI, including PASSR screening, H&P, MD/NP progress notes, MARs, MD orders, nursing and therapy notes, care plans, NOMNC, insurance eligibility, and consent/hospital records, copied to an unencrypted, non–password-protected USB drive after the authorized representative requested a complete medical record. The MRD mailed the USB via certified mail when email transmission failed due to file size, and the envelope was later returned torn open and without the USB, resulting in unauthorized exposure of the resident’s PHI despite a facility policy requiring protection of PHI privacy.
The facility lacked a policy and procedure governing the use of USB drives for transmitting PHI, leading to an incident in which a resident’s complete medical record was saved to an unencrypted, non–password-protected USB drive and mailed to the resident’s authorized representative. After email transmission failed due to large file size, the MRD used a USB drive containing the resident’s medical records, medical record number, insurance details, residency dates, and share of cost, and sent it by certified mail. The envelope was later returned torn open with the USB drive missing. The ADM acknowledged that existing PHI policies were outdated and did not address USB drives or current technology.
A resident with malignant neoplasm, muscle weakness, and impaired mobility expressed a preference, through IDT discharge planning, to return to the community, with the goal of transfer to an assisted living or board and care closer to a family member. The family member requested a specific receiving facility and provided its name to social services. The Social Services Director sent clinical information to that facility, which declined admission, but did not inform the family of the denial and did not offer alternative facility options or referrals to community agencies or support services. This inaction conflicted with the facility’s discharge policy requiring resident/representative involvement in discharge planning and referrals to local agencies when a resident is interested in returning to the community.
A resident with malignant neoplasm, muscle weakness, and impaired mobility had intact cognition and documented preferences for activities such as exercise, TV, music, and spiritual visits. The activity assessment noted that recreation staff provided an activity calendar and discussed potential group activities. A family member reported the resident stayed in bed all day without activities. The AD stated that activity staff greet residents daily, offer group activities, and provide documented room visits for those who do not attend groups. However, review of the electronic records showed no documentation of room visits or activities for this resident over an extended period, and the AD admitted she had conducted room visits on the resident’s unit but failed to document them, contrary to facility policies requiring complete and accurate charting of services provided.
A resident with cognitive impairment and full dependence on staff for personal care was unable to alert staff for assistance due to a non-functional call light above their door. The issue was confirmed by both a CNA and the DON, and facility policy requiring regular checks of the call system was not followed.
Several residents with severe cognitive impairment and total dependence on staff were found to have damaged bed rail padding and a broken wall molding in their rooms. The damaged padding was ripped and gouged, exposing porous foam and bed rails, while the wall molding behind a resident's bed was missing a piece. Staff confirmed that these issues had not been reported or repaired as required by facility policy, resulting in an environment that was not safe, clean, or comfortable.
Two residents with significant medical needs were found with both upper and lower bed side rails raised, despite only having consent and physician orders for upper rails. Required assessments and consents for lower rail use were not completed, and staff confirmed this practice was against facility policy and could be considered a restraint.
Two residents did not receive accurate assessments: one was incorrectly coded for schizophrenia in the MDS despite being in a persistent vegetative state and lacking supporting documentation, while another had hearing impairment that was not properly documented or followed up, resulting in delayed access to hearing aids and services. These assessment failures led to inaccurate care planning.
Two residents did not have updated, comprehensive care plans to address significant clinical needs: one with a stage II pressure ulcer did not have a care plan for wound care and treatment, and another with a recent diet order change did not have a care plan reflecting the new mechanical soft diet. Staff were unaware of these changes due to the lack of updated care plans, contrary to facility policy requiring timely and person-centered care planning.
A resident with significant medical issues and documented hearing impairment was not provided with timely access to audiology services or hearing aids, despite an active order and recommendations from an ENT. Missed and cancelled appointments, lack of in-house audiology services, and incomplete assessments contributed to the resident waiting approximately six months without needed hearing support.
Multiple residents at high risk for falls and injury did not receive required safety interventions, including the absence of physician-ordered floor mats at the bedside for two residents, a resident with ripped bed rail padding exposing a hard surface, and another resident with incomplete fall risk assessments. Staff and DON confirmed these deficiencies, and facility policies requiring such interventions were not followed.
The facility did not reconcile controlled medications in two emergency medication kits at every shift, as required by policy. Both a medication room and a medication cart were found to have eKITs containing controlled substances without accountability logs for shift-by-shift reconciliation. Nursing staff confirmed the lack of reconciliation and documentation, which was inconsistent with facility procedures for controlled medication handling.
Two residents experienced medication errors when a nurse administered a blood pressure medication outside the prescribed time window and another nurse failed to give a stool softener as ordered and provided the wrong type of multivitamin. These actions resulted in a medication error rate above 5%, contrary to facility policy and physician orders.
Surveyors found that staff failed to remove and discard expired or improperly stored medications, including insulin and Procrit, for three residents. An opened insulin pen was kept past its expiration date, another insulin vial was stored without an open date and at the wrong temperature, and a single-dose Procrit vial was not discarded after use. Nursing staff and the DON confirmed these medications were not handled per policy, and facility procedures require proper labeling, storage, and timely disposal of such medications.
Staff failed to consistently prepare and serve food at required temperatures, with hot foods served below 135°F and cold foods above 40°F. Dietary staff did not always check or record food temperatures, and some items were left at room temperature before service, placing many residents on regular, therapeutic, and puree diets at risk.
Staff prepared pureed pasta for residents on a pureed diet without measuring thickening agents, resulting in a sticky, lumpy texture that did not meet required standards. Dietary staff and the RD confirmed the food was not smooth as required by policy and IDDSI guidelines, potentially affecting 18 residents who require pureed diets due to chewing and swallowing difficulties.
Multiple deficiencies were identified in dietary services, including unlabeled and undated opened frozen foods, unsanitary kitchen equipment and storage areas, damaged and rusted shelving and utensils, improper staff hygiene practices such as wearing jewelry and nail polish during food preparation, improper storage of dented cans, wet stacking of clean dishware, lack of separation between clean and dirty areas, and failure to monitor freezer temperatures. These issues were confirmed through direct observation and staff interviews.
Failure to Protect Resident PHI
Penalty
Summary
The facility failed to ensure residents’ personal and medical records remained private and confidential when a diet type report containing protected health information was discarded in a trash container instead of being shredded. During an observation on 4/20/2026 at 8:22 a.m., a diet type report for all stations dated 4/13/2026 was observed in the trash and contained residents’ names, room numbers, diet orders, and allergies. During a concurrent observation and interview on 4/20/2026 at 9:13 a.m., the Dietary Supervisor confirmed the diet type report was found in the trash and stated it should not have been discarded there because it was a HIPAA violation. The Dietary Supervisor stated the report contained residents’ names, diet orders, and room numbers, which are protected information. A review of the facility’s policy titled Notice of Privacy Practices, dated 11/25/2025, showed the facility’s privacy practices and the use and disclosure of PHI were addressed, and that staff would be trained on the privacy notices upon hire and annually.
Care Plans Not Developed or Implemented for Restraints, Oxygen, Anticoagulation, and Vaccine Refusal
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable interventions for several residents with identified needs. For three residents with orders for physical restraints that included holiday breaks, the care plans did not include specific interventions for monitoring behavior when the restraints were removed on the holiday days. Resident 14 had diagnoses including acute respiratory failure with hypoxia and required a left upper extremity freedom splint to prevent pulling at a tracheostomy tube and gastrostomy tube; on a holiday day, he was observed in bed without the restraint and scratching his face. Resident 1 had diagnoses including acute respiratory failure with hypoxia, tracheostomy, gastrostomy, and encephalopathy, and Resident 8 had diagnoses including acute respiratory failure with hypoxia, tracheostomy, gastrostomy, and traumatic subdural hemorrhage; both had restraint orders with holidays off, but their care plans did not specify how staff were to monitor them when the restraints were not in place. The facility also did not implement oxygen-related care plan interventions for two residents. Resident 191 had chronic respiratory failure and was ordered humidified oxygen at 5 L/min; during observation, the oxygen concentrator was on but the tubing was not connected to the resident, and the tubing was lying on the bed and was not dated. Resident 90 had acute respiratory failure and dysphagia and was ordered humidified oxygen at 5 L/min via TBar/Tmask; during observation, the oxygen tubing was not dated. In both cases, the care plans addressed oxygen therapy and weekly tubing changes, but the documented interventions were not carried out as written, including dating the tubing per facility policy. Resident 191’s anticoagulant care plan was also not implemented. The resident was receiving apixaban for DVT prophylaxis and the care plan identified a risk for bleeding and bruising, with an intervention to assess for signs and symptoms of bleeding such as blood in the urine or stool and coffee ground emesis and notify the physician. During record review, the ADON stated there was no documentation showing nursing staff assessed or monitored the resident for bleeding signs and symptoms. In addition, Resident 76, who was cognitively intact and had capacity to make decisions, refused the 2025/2026 influenza vaccine, but no care plan was developed to address the refusal. The IPN stated the resident’s refusal was not documented in a care plan, and the DON stated a care plan should include education about why the vaccine is needed and reoffering the flu vaccine.
Respiratory Care: Oxygen Tubing Not Dated and Ordered Oxygen Not Provided
Penalty
Summary
The facility failed to provide necessary respiratory care for two residents who were receiving oxygen therapy. Resident 90 had diagnoses including acute respiratory failure, dysphagia, and encephalopathy, and the MDS indicated severely impaired cognitive skills for daily decision making. The resident’s care plan, initiated on 4/11/2023 and last revised on 2/26/2026, indicated oxygen therapy for respiratory failure with an intervention to change oxygen tubing weekly or as needed. During observation on 4/20/2026 at 10:44 a.m., Resident 90 was in bed receiving oxygen at 5 L/min via TBar/Tmask, and the oxygen tubing was not dated. The ADON stated it was important to date the tubing so staff would know when it was due for change per policy and for infection control. Resident 191 had diagnoses including hypertension, chronic respiratory failure, and functional quadriplegia, and the MDS indicated severely impaired cognitive skills. The physician phone order report showed an order for humidified oxygen at 5 L/min with routine scheduling every day, every 6 hours, and the care plan, initiated on 1/14/2021 and last revised on 4/04/2026, indicated oxygen therapy for respiratory failure with interventions to change oxygen tubing weekly or as needed and provide oxygen as ordered. During observation on 4/20/2026 at 10:55 a.m., Resident 191 was in bed without oxygen in place while the oxygen concentrator was on and delivering oxygen at 5 L/min. The oxygen tubing was not connected to the concentrator, was lying on the bed next to the resident, and was not dated. RT 1 confirmed the oxygen was not connected to the resident and stated the resident had a physician order for continuous oxygen. Staff interviews and record review confirmed the deficiencies. CNA 1 stated she had showered Resident 191 that morning and forgot to ask licensed staff to place the resident back on oxygen. RT 2 stated the order meant Resident 191 should receive continuous oxygen at 5 L/min, and that the every 6 hours instruction referred to documenting that the oxygen was being received. ADON 1 stated the care plan interventions for Resident 191 were not implemented and that licensed nursing staff should date the oxygen tubing so staff know when it is due for change and to prevent infection. The DON stated oxygen tubing should be dated and changed weekly per facility policy. The facility policy stated oxygen tubing should be changed weekly and as needed, and the date, time, and initials should be noted when oxygen equipment is initially used and when changed.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to maintain accurate and current daily nurse staffing postings for the SNF and Subacute unit in accordance with its policy titled Posting Direct Care Daily Staffing Numbers. During observation on 4/22/2026, a framed Daily Staffing Posting dated 4/20/2026 was seen in the SNF Nurse's Station 1, and the Director of Staff Development (DSD) stated the posting was outdated and did not include the actual resident census or the actual total hours worked by RN, LVN, and CNA staff for the SNF and Subacute unit. The DSD also stated the facility's practice was to post projected nursing hours rather than actual hours, and that Accounts Payable/Payroll calculated actual hours on the following business day for filing. The DSD further stated the facility did not post staffing information for 4/21/2026 and 4/22/2026 in the SNF area as required. She explained that she completed the staffing form sections for date, census at start of shift, projected PPD, actual hours worked, and staffing totals for both units using pencil. In the Subacute Nurse's Station, a Daily Staffing Posting dated 4/22/2026 was observed, and the DSD stated the section labeled Actual Hours Worked for the day, evening, and night shifts was incorrect because it reflected projected hours rather than actual hours worked. She stated actual hours can only be entered after the shift is completed. During interview and record review, the DON confirmed the staffing posting displayed in the SNF was dated 4/20/2026 and stated staffing must be posted daily within two hours of the beginning of each shift in the designated area. The DON stated the posting was missing the actual resident census and actual hours worked by licensed and unlicensed nursing staff, and that the facility did not follow its policy. The DON also stated the forms should have been completed in black ink rather than pencil to prevent changes to the information, as required by policy.
Missed and Delayed Medication Administration
Penalty
Summary
The facility failed to provide ordered medications to residents because several medications were not available in the facility at the time they were due. Resident 87 did not receive oyster shell calcium on 4/21/2026 at 9:45 a.m. because the medication was not available in Medication Cart Subacute Cart 2 or in the facility. During the observation, LVN 4 administered the resident’s other scheduled medications via G-tube but did not administer oyster shell calcium. LVN 4 stated the medication was house supply and was not available for administration at the scheduled time. Resident 201 also missed ordered medications because the facility did not have glipizide or menthol-methyl salicylate cream available. During the 4/20/2026 medication pass, LVN 2 administered gabapentin and metformin orally but did not administer glipizide or menthol-methyl salicylate cream. LVN 2 stated both medications were not available in Medication Cart Station 3 or in the facility. Record review showed glipizide had last been delivered on 3/13/2026 as a 31-day supply, and the facility had not received additional delivery, resulting in missed doses between 4/16/2026 and 4/20/2026. The DON also acknowledged there were no manifests or delivery records for menthol-methyl salicylate cream and that the resident had not received it since 4/9/2026. Resident 84 had a lidocaine 5% patch still on the right shoulder when it was observed during medication cart review on 4/20/2026 at 9:40 a.m. The patch was labeled 4/19/2026, and LVN 2 removed it during the observation. LVN 2 stated the patch had remained on the resident’s shoulder beyond the ordered 12-hour removal time and that LVN 5 had failed to remove it at the scheduled time. The DON stated licensed nurses were expected to follow medication administration guidelines and the five rights of medication administration, and acknowledged the facility failed to ensure the ordered medications were available and administered as prescribed.
Medication error rate exceeded allowable threshold
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. Surveyors identified 4 medication errors out of 26 opportunities, resulting in a 15.38% error rate and affecting three residents during observed medication administration. The errors involved omitted doses of sevelamer for a resident with kidney disease and dialysis dependence, oyster shell calcium for a resident with dysphagia, and both glipizide and menthol-methyl salicylate cream for a resident with type 2 diabetes mellitus and pain. During medication administration observation, an LVN administered several ordered medications to one resident but did not administer sevelamer, which was ordered three times daily for hyperphosphatemia. In interview, the LVN acknowledged the omission and stated the dose had been documented as given even though it was not prepared or administered. The LVN stated the omission was a medication error and noted that missing sevelamer could further increase blood phosphate levels. In a separate observation, another LVN administered multiple medications to a resident via G-tube but did not administer oyster shell calcium, which was ordered once daily. The LVN stated the medication was not available in the cart or facility and that the omission was a medication error. For a third resident, an LVN administered gabapentin and metformin but did not administer glipizide or menthol-methyl salicylate cream, both of which were ordered for the morning dose. The LVN stated those medications were not available in the facility and that the missed doses were medication errors. The DON confirmed that the facility failed to ensure medications were available and that the omissions resulted in significant medication errors and interruption of continuity of care.
Significant Medication Errors Due to Missed Glipizide Doses
Penalty
Summary
Resident 201, who had a diagnosis of DM Type 2, was prescribed glipizide 2.5 mg by mouth once daily at 9 a.m. The resident’s April 2026 MAR showed that glipizide was not administered on multiple days between 4/16/2026 and 4/20/2026. During observation on 4/20/2026 at 10:10 a.m., LVN 2 administered gabapentin and metformin to the resident but did not administer the scheduled glipizide dose. During interview and record review, LVN 2 stated glipizide was not given because it was not available in Medication Cart Station 3 or in the facility. LVN 2 acknowledged that the missed doses on the MAR between 4/16/2026 and 4/20/2026 were medication errors and stated that medications should be ordered in advance and followed up as needed with pharmacy to ensure timely availability. LVN 2 also stated that glipizide was used to control blood sugar levels and that missing doses could harm the resident by causing high or low blood sugar levels and unresponsiveness resulting in potential hospitalization. The DON reviewed the MAR and stated facility policy required medications to be ordered seven days in advance and to be readily available for administration at scheduled times. The DON stated LVN staff were expected to reorder medications timely and follow up on refills to ensure availability. The DON acknowledged that glipizide was not administered daily between 4/16/2026 and 4/20/2026 and identified these missed doses as significant medication errors. RN 2 also reviewed the MAR and acknowledged that the documented non-administration of glipizide during that period was a significant medication error.
Expired eye drops and undated inhalation medication found in medication carts
Penalty
Summary
Medication storage and labeling practices failed for two residents in two medication carts. In Medication Cart 1B, an open levalbuterol inhalation solution foil pouch for Resident 99 was found stored at room temperature without a date showing when the pouch was opened. During interview, the LVN stated the pouch was not labeled with an open date and acknowledged that multi-dose products should be dated when first opened so their expiration can be tracked. In Medication Cart 2B, an open latanoprost eye drop bottle for Resident 26 was found stored at room temperature with a label showing it was opened on 3/1/2026 and instructions to discard after 28 days. The DON stated the bottle had expired on 4/12/2026 and was not removed from use from the cart. The DON also stated the bottle was used between 4/13/2026 and 4/19/2026, and that eye drop bottles are multi-dose medications with a six-week expiration after opening according to the manufacturer. Record review showed the facility policy required medications to be stored safely and properly according to manufacturer recommendations, outdated medications to be immediately removed from stock, and multi-dose containers to be dated when opened. The facility policy also stated ophthalmic preparations are discarded 28 days after opening and levalbuterol is discarded 2 weeks after opening the foil pouch. Manufacturer information reviewed by surveyors stated opened latanoprost bottles may be stored at room temperature for 6 weeks and opened levalbuterol foil pouches should be used within 2 weeks.
Food Served at Improper Temperatures and Vegetables Overcooked
Penalty
Summary
Food and drink were not prepared and held in a manner that conserved appearance, flavor, and temperature. On 4/20/2026, cold items on the trayline, including pudding, fruit cup, and spring fruit crisp, were observed without ice and measured above cold-holding temperatures. The Dietary Supervisor stated these items were not cold, that cold foods should be 40 F or below, and that residents would not be satisfied and might not eat food served at those temperatures. During the same observation, capri blend vegetables were described as mushed and brownish green, and the Dietary Supervisor stated they were overcooked and needed to be more colorful and less cooked to preserve vitamins and nutrients. Resident 76 had diagnoses including HTN, type 2 diabetes, and dysphagia, and required supervision or touching assistance with eating. During a resident council interview, Resident 76 stated breakfast sausage was cold and pink inside, the food had been cold lately, and breakfast and lunch had been coming out later, with lunch not received until 2:00 p.m. that day. Resident 130 had diagnoses including HTN, type 2 diabetes, and hyperlipidemia, and required set up and clean up assistance with eating. Resident 130 stated foods were served cold at different times. The facility menu for 4/20/2026 included baked hamburger, brown sauce, diced fried potatoes, capri blend vegetables, wheat roll, margarine, spring fruit crisp, and milk. On 4/22/2026, a test tray for breakfast showed sausage at 88 F, waffles at 95 F, oatmeal at 130 F, and whole milk at 45 F. The Dietary Supervisor stated the food could be hotter and that a delayed trayline due to additional resident requests made the food not hot. The Registered Dietitian stated it was important to have meals on time to prevent resident dissatisfaction and to keep temperatures palatable. Resident 169, who had Parkinson's disease, vitamin B12 deficiency anemia, and major depressive disorder, required set up and clean up assistance and stated most of the time breakfasts were served cold.
Improper Texture of Pureed Foods
Penalty
Summary
The facility failed to prepare puree foods in a form designed to meet individual needs for residents on an IDDSI Level 4 puree diet. During observation of the trayline and plated meals, the pureed capri blend vegetables looked flat and spread out on the plate, and the puree spring fruit crisp appeared watery and did not hold its shape. No spoon tilt test or fork pressure test was observed being performed by kitchen staff during trayline service to verify the texture and consistency of the pureed foods. During interview, the Dietary Supervisor stated the pureed capri blend vegetables did not hold their shape and the puree spring fruit crisp looked watery, and that pureed food should not look flat or watery because residents could choke and aspirate. The Registered Dietitian stated staff should perform spoon tilt and fork pressure tests when making food and during trayline to ensure the correct texture for residents with difficulty swallowing and eating. Facility documents for the IDDSI Level 4 pureed diet and related recipes stated the food should be smooth, free of lumps, hold its shape, and not weep, and the IDDSI guidance stated Level 4 pureed food should hold shape on the plate and not allow liquid to separate from solid.
Late Meal Service
Penalty
Summary
The facility failed to provide meals at regular scheduled times in accordance with resident needs, preferences, and requests when lunch was served late on 4/22/2026. The deficiency affected 124 to 125 residents receiving meals from the kitchen, including two residents who were interviewed during resident council and reported that lunch had arrived nearly 2:00 p.m. and that breakfast and lunch had been arriving late recently. One resident had diagnoses including HTN, type 2 diabetes, and dysphagia, and the other had diagnoses including HTN, hyperlipidemia, and CHF; both were assessed as understanding others and making themselves understood and needed supervision or touching assistance when eating. Meal service observations showed the posted schedule listed breakfast at 7:30 a.m., lunch at 12:30 p.m., and dinner at 5:30 p.m. On 4/20/2026, dietary staff did not begin lunch trayline until 12:48 p.m., the first cart did not reach the dining room until 12:58 p.m., trayline finished at 2:08 p.m., and the last tray cart reached the station at 2:11 p.m.; nursing staff were still passing trays at 2:14 p.m. through 2:18 p.m. On 4/22/2026, breakfast trayline began at 7:33 a.m., the first cart left the kitchen at 7:56 a.m., the last breakfast tray was prepared at 9:04 a.m., and nursing staff finished passing the last tray at 9:13 a.m. During interview, the Dietary Supervisor stated the breakfast trayline runs from 7:30 a.m. to 8:30 a.m. and that the trayline was delayed because of food production for special resident requests, including extra omelets. The Dietary Supervisor stated the delay was not reasonable and that meals should be served on time because residents expect them at a certain time. The Registered Dietitian stated it was important for meals to come on time to prevent resident dissatisfaction and to keep food temperatures palatable. The facility policy stated residents' meals would be served at regular hours, with an unavoidable variance of 15 minutes considered acceptable, and listed lunch service as 12:30 p.m. to 1:30 p.m.
Kitchen sanitation, hand hygiene, and food storage failures
Penalty
Summary
Safe food storage and sanitation practices were not consistently followed in the kitchen during multiple observed events. An iced brown drink with a straw was observed stored in the pitcher storage area near the trayline. The Dietary Supervisor stated personal eating and drinking were not allowed in the kitchen because saliva could contaminate food and cause cross-contamination. The facility’s sanitation and infection control policy stated employee personal belongings, including food and drinks, should be stored separately from food service items. Hand hygiene was not performed at several points during food preparation and dishwashing. A Dietary Aide sneezed near the trayline, covered his mouth with gloved hands, removed the gloves, and returned to serving breakfast without washing his hands. He also touched his hair and later touched his mask, then continued working at the trayline without handwashing. During dishwashing, he moved pans from one 2-compartment sink area to another and placed them into the sanitizer and drying area without washing his hands or changing gloves. Another staff member touched the lid of a trash can and then handled a pan containing puree food without washing her hands. The facility’s policies and the Food Code sections reviewed stated handwashing was required after sneezing, touching the face or hair, handling waste, and before handling food or clean equipment. Temperature monitoring and sanitation controls were also inconsistent. Refrigerator and freezer logs were missing documented temperatures for some shifts, and a resident freezer by Station 1 had no thermometer and was not being monitored. Multiple kitchen and resident food storage areas were observed with dirt, dust, spills, residue, and debris, including the reach-in refrigerator, dry storage shelves, condiment containers, the mixer, the vent near the preparation area, and the resident refrigerator at Station 1. Seven dented cans were stored with non-dented cans. During trayline and dishwashing activities, resident trays were not allowed to air-dry and were wiped with the same paper towel, pans were stacked wet, soap residue was present in the drying area, and a staff member did not follow the required QUAT sanitizer contact time or testing procedures, including the required test-strip immersion time and temperature range. The report states these failures had the potential to result in harmful bacterial growth and cross contamination for medically compromised residents who received food and ice from the kitchen.
Improper Garbage Storage and Unsanitary Dumpster Area
Penalty
Summary
Garbage and refuse were not properly disposed of in the dietary area when a trash container by the preparation area was observed not to be covered while it was not actively in use. During the observation, the Dietary Supervisor confirmed that the trash can should have been kept closed with a lid to prevent cross-contamination and stated that none of the staff were using it at the time. The Dietary Supervisor also stated that the container should be covered because it could attract flies that may contaminate residents' food and potentially cause foodborne illness. In a separate observation, dark liquid spills were seen on the ground surrounding the dumpster. The Dietary Supervisor stated the substance was unknown and could be anything, and the Maintenance Supervisor stated the area was only cleaned with brooms. Both the Dietary Supervisor and Maintenance Supervisor stated the surrounding dumpster area should be kept clean and free of spills and trash, and the facility policy indicated that outside garbage bins should be kept closed at all times and the surrounding area kept clean.
Inaccurate clinical documentation for diagnoses, side rail consent, and MAR entries
Penalty
Summary
The facility failed to accurately document medical diagnoses and the POLST for one resident. Resident 211’s face sheet listed diagnoses including cerebral infarction, nontraumatic subarachnoid hemorrhage, and hypertension. The history and physical dated 4/10/2026 also identified depression, but the current medical diagnoses did not include depression. During review of Resident 211’s POLST, the Social Services Director stated the form was filled out incorrectly because the advanced directive date was listed as 4/9/2026 instead of 7/19/2025. The Assistant Director of Nursing acknowledged that depression was mistakenly omitted from the medical diagnoses list. The facility also failed to maintain accurate documentation related to side rail consent for Resident 19. The resident’s records showed an order for bilateral upper and lower half side rails up and locked when in bed for ADL changes. Resident 19 was observed in bed with bilateral upper and lower side rails up and locked. Staff stated there was a signed informed consent for upper side rails only, but they could not locate a signed informed consent for the lower side rails. The Assistant Director of Nursing stated she could not find documentation showing the responsible party was notified or that consent was obtained for the lower side rail, and she stated the documentation was not accurate. The Director of Nursing stated licensed nursing staff should have obtained informed consent for the lower half side rails. The facility also inaccurately documented medication administration for Resident 201. The resident had an order for menthol-methyl salicylate cream to the left hand twice daily for pain. The April 2026 MAR showed 17 documented administrations by multiple licensed nurses between 4/9/2026 and 4/20/2026. However, during observation and interview, LVN 2 stated the medication was not available in the facility and was not administered as prescribed. The DON confirmed there were no manifests or delivery records for the medication and acknowledged the facility had not received it since 4/9/2026. The DON and RN 2 both stated the MAR was inaccurately documented because doses were charted as given when the medication was not available.
Delayed Influenza Vaccination and Documentation
Penalty
Summary
The facility failed to offer the 2025/2026 influenza vaccine at the start of the respiratory illness season for four sampled residents who were investigated for immunizations. Resident 1 was originally admitted on 8/22/2025 and readmitted on 4/6/2026 with diagnoses including acute respiratory failure with hypoxia and anemia. A physician progress note indicated the resident did not have the capacity to understand or make decisions, and the MDS showed the resident rarely or never understood others, could rarely or never express ideas and wants, and was dependent on staff for all ADLs. The resident’s responsible party consented to the flu vaccine on 3/15/2026, and the MAR showed the vaccine was administered on 3/30/2026. Resident 2 was readmitted on 2/8/2026 with diagnoses including traumatic subdural hemorrhage and COPD. The H&P indicated the resident had capacity to understand and make decisions, and the MDS showed the resident was cognitively intact but dependent on staff for several ADLs. The resident consented to the flu vaccine on 3/20/2026, and the Immunization Details showed the IPN administered the vaccine on 3/30/2026. Resident 13 was readmitted on 2/12/2026 with diagnoses including respiratory failure and dependence on a ventilator. A SOAP note indicated the resident was minimally alert, not oriented, and non-communicative, and the MDS showed the resident rarely or never understood others, could rarely or never express ideas and wants, and was dependent on staff for all ADLs. The resident’s responsible party consented on 2/4/2026, and the Immunization Details showed the vaccine was administered on 3/31/2026. Resident 20 was readmitted on 2/9/2026 with diagnoses including hydrocephalus and respiratory failure. A physician progress note indicated the resident did not have the capacity to understand or make decisions, and the MDS showed the resident rarely or never understood others, could rarely or never express ideas and wants, and was dependent on staff for all ADLs. The resident’s responsible party consented on 3/16/2026, and the Immunization Details showed the vaccine was administered on 3/31/2026. During interview, the IPN stated Resident 1 was vaccinated on 3/31/2026 but the vaccination was not recorded in the EMR Immunization Details, and stated the residents were present in the facility during the fall of 2025 but were not vaccinated until late March. The IPN stated she was waiting to vaccinate residents together at the end of March, rather than earlier in the season or soon after admission. The DON stated there was no vaccine shortage and that the flu vaccine should be given right away, ideally in October, after it becomes available. The facility policy stated the influenza vaccine would be offered annually in accordance with current CDC recommendations.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide care in a manner that maintained dignity and respect for two residents. For one resident with dementia, a tracheostomy, ventilator dependence, and total dependence for activities of daily living, the Infection Preventionist Nurse entered the room from the hallway without knocking or asking permission and then began pulling the curtain closed. The nurse stated she forgot to knock before entering, and the Director of Nursing stated that anyone entering a resident’s room must knock and ask permission before entering and that resident privacy should be respected. For another resident with severe protein-calorie malnutrition, neurogenic bladder, and urinary retention, the resident had a Foley catheter with a drainage bag attached to the bedside. During observation, the catheter collection bag was seen anchored to the trash container next to the bed with clear yellow urine visible to public view. Registered Nurse 2 stated the urine collection bag should be covered with a dignity bag to maintain privacy. The Assistant Director of Nursing also stated that placing the urine collection bag in a dignity bag protects privacy and keeps urine out of public view. The facility’s policies stated that residents are to be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and personal care, and that staff are expected to knock and request permission before entering a resident’s room. The dignity policy also stated that residents are to be cared for in a manner that promotes self-worth and self-esteem and that staff are expected to help keep urinary catheter bags covered.
Failure to Obtain Informed Consent for Lower Side Rails
Penalty
Summary
The facility failed to implement its Side Rails policy for one resident by not obtaining informed consent for the use of lower side rails. Resident 19 was admitted with diagnoses including hypertension, diabetes type 2, and Alzheimer's disease, had a designated POA agent, and was documented in the H&P as able to make needs known but unable to make medical decisions. The MDS showed moderately impaired cognitive skills for daily decision making and dependence on staff for multiple transfers and mobility tasks. The resident had an order for bilateral upper and lower half side rails up and locked when in bed for ADL changes, and staff observed the resident in bed with the upper and lower side rails up and locked. RN 1 and ADON 1 reviewed the informed consent and stated they could locate a signed consent for upper side rails only, but not for lower side rails. The MAR showed the bilateral upper and lower half side rails were up and locked continuously for more than three months, and the DON stated licensed nursing staff should have obtained informed consent for the lower half side rails in accordance with facility policy and resident rights.
Advance Directive Not Clarified With Healthcare Agent
Penalty
Summary
The facility failed to clarify the wishes written on Resident 211’s advance directive with the healthcare agent when the resident’s physician orders did not match the advance directive. Resident 211 was admitted with diagnoses including cerebral infarction, nontraumatic subarachnoid hemorrhage, and hypertension, and the MDS indicated severely impaired cognitive skills for daily decision making. The resident also required extensive assistance with toileting hygiene, bathing, dressing, and bed mobility. The Order Summary Report and Baseline Care Plan both indicated the resident was to attempt resuscitation, and the POLST dated [DATE] also indicated attempt resuscitation and full treatment. However, the advance directive dated [DATE] stated that Resident 211 did not want to prolong life. During interview and record review, the SSD stated the POLST should have indicated selective treatment as reflected in the advance directive and that the resident’s family should have been called to clarify the resident’s wishes. The facility policy titled Advance Directive Acknowledgement stated it was to support resident rights in making decisions regarding care and treatment as instructed on the advance directive.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two sampled residents. Resident 50 was admitted and later readmitted with diagnoses including emphysema, history of falls, and muscle weakness. His H&P indicated he had the capacity to understand and make decisions, and his MDS indicated he could make himself understood and understand others, but he required supervision for oral hygiene, toileting, upper body hygiene, and personal hygiene. During observation, Resident 50 threw trash into a bin labeled “URINAL ONLY,” which already contained a urinal and other trash, and he stated he did not have another trash bin in his room and would like one. The ADSD observed that trash should not be placed in the urinal-only bin and stated the resident should have his own trash bin in his room. The ADON also stated the resident should have his own trash bin to maintain a homelike environment. Resident 13 was readmitted with diagnoses including respiratory failure and dependence on a ventilator. A SOAP note indicated the resident was minimally alert, not oriented, and non-communicative, and the MDS indicated the resident rarely or never understood others, rarely or never expressed ideas and wants, and was dependent on staff for all ADLs. During observation at the bedside, Resident 13’s floor mat was in poor condition and coming apart at the edges, and there was a dried dark red substance on the bed frame along with trash and a towel on the floor under the bed. On follow-up observation, the dried dark red substance and trash remained, and the floor mat was still in place. An LVN stated he picked up the trash and cleaned the substance off the bed frame, and the DON stated the floor mat was not maintained in proper condition and posed a potential safety risk. The facility policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment.
Failure to Follow Restraint Holiday Order
Penalty
Summary
The facility failed to remove one resident’s left-hand mitten restraint in accordance with the physician’s order. Resident 8 was admitted and later readmitted with diagnoses including acute respiratory failure with hypoxia, tracheostomy, gastrostomy, and traumatic subdural hemorrhage. The resident’s MDS dated 3/20/2026 indicated severely impaired cognitive skills for daily decision making, and the resident required extensive assistance with toileting hygiene, bathing, dressing, and bed mobility. The order summary dated 4/22/2026 included an order from 1/12/2026 to apply a hand mitten to the left hand to prevent pulling out the tracheostomy tube and scratching, with removal every two hours for 15 minutes for circulation and skin integrity checks, and with holidays off on Wednesdays and Sundays. During observations on 4/22/2026, the resident was seen in bed with the left-hand mitten on at 10:21 a.m. and again at 11:30 a.m. During interview, the ADON stated the order to remove the mitten on holidays was not followed because the resident was still wearing the mitten on the left hand. The facility policy on restraint holidays stated that holidays from restraints provide residents who are not appropriate for restraint reduction with a temporary break from restraints.
Incomplete Admission Comprehensive Assessment
Penalty
Summary
The facility failed to complete an admission comprehensive assessment within the required timeframe for one of three sampled residents, Resident 211. The resident’s Face Sheet showed admission with diagnoses including cerebral infarction, nontraumatic subarachnoid hemorrhage, and hypertension. The Minimum Data Set dated 4/21/2026 indicated the resident had severely impaired cognitive skills for daily decision making and required a helper to do all of the effort for toileting hygiene, showering/bathing, dressing, sit-to-lying, and lying-to-sitting on the side of the bed. During a concurrent interview and record review on 4/23/2026 at 12:50 p.m., the Assistant MDS Nurse reviewed the admission comprehensive assessment dated 4/21/2026 and confirmed it was still in progress and not completed. The AMDS stated the assessment should have been completed on 4/22/2026 but could not be closed because four areas were incomplete, including sections from Social Services and Dietary. The CMS RAI version 2.0 stated the admission comprehensive assessment was to be completed no later than 13 days after the admission date, which was 4/22/2026.
Delayed MDS Transmission for Two Residents
Penalty
Summary
The facility failed to ensure that MDS assessments were transmitted timely to CMS for two residents. For Resident 22, the record showed an original admission on 5/24/2023 and a later readmission, with diagnoses including DM. The MDS indicated the resident had moderately impaired cognition, required supervision or touching assistance with eating, and had a planned discharge. The census report showed the resident was discharged on 1/28/2026, and the physician order and nursing progress note both documented discharge to a board and care facility on that date. Resident 22’s MDS Summary showed the ARD for the discharge assessment was 1/28/2026 and that the MDS was to be completed by 2/11/2026, but the assessment was still in progress at the time of review. During interview, the MDSN stated there was no discharge MDS completed for Resident 22 when discharged and that the discharge assessment should have been completed within 14 days. The MDSN stated he was not sure why it was not completed and submitted, and noted that timely completion is important so CMS can know a resident’s functioning status and monitor for improvement or decline. The MDS record later showed the assessment was signed as completed on 4/24/2026. For Resident 166, the record showed an original admission on 12/02/2025 and a later readmission, with diagnoses including chronic respiratory failure with hypoxia. The MDS indicated the resident had severely impaired cognition, was dependent on staff for dressing and personal hygiene, and the assessment was for an unplanned discharge. The census report showed the resident was transferred to the hospital on 1/30/2026, and the MDS Summary showed the ARD for the discharge assessment was 1/30/2026 with a completion date of 2/17/2026. During interview, the MDSN stated the discharge assessment should have been completed within 14 days and that the completion date should have been 2/13/2026, but he was not sure why it was not completed timely. The DON stated the MDSN should have completed both residents’ MDS assessments according to MDS guidelines so there would be no delays in care and discharge plans would be implemented.
Failure to Notify Physician of Biopsy Refusal and Obtain Ongoing Wound Orders
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident with severe protein-calorie malnutrition, neuromuscular dysfunction of the bladder, and urinary retention who was able to make himself understood and understand others. The resident had a sore on the right temple that was observed with an adhesive bandage, and he stated the area was beneath the bandage and that he did not like how it looked. He also stated ointment was applied to the sore and the bandage was changed by the nurse in the morning. The resident had been seen by dermatology for prurigo nodularis of the right temple, and the dermatology notes indicated topical steroids were being used and that the resident refused a biopsy. The notes from a later dermatology visit again indicated the resident refused biopsy. The LVN stated she did not notify the resident’s primary physician of either refusal, and the ADON stated the nurse should have notified the physician when the resident refused the biopsy recommended by the dermatologist. The resident’s order for clobetasol propionate cream, cleansing with normal saline, pat dry, and dry dressing was last administered on 4/10/2026, and there were no current treatment orders for the right temple sore beginning the next day. The LVN stated she had been leaving the sore open to air because it was dry and had no drainage, or applying an adhesive bandage per the resident’s request, and stated she should have obtained orders for the appropriate care. The ADON stated physician orders should have been obtained when there were no longer active treatment orders to follow, and the delay in obtaining orders delayed delivery of care.
Improper Use of Low Air Loss Mattresses for Two Residents
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALM) were used correctly for two residents with pressure ulcer-related needs. For Resident 155, the physician ordered LALM for wound care and management, and the care plan directed that the mattress be inflated as recommended. During observation, the LALM was found set at 499 pounds instead of 160 pounds. The Assistant Director of Nursing stated the mattress had been left on the firmer setting for care and should have been returned to 160 pounds afterward, and that keeping a resident on a firm setting can cause skin breakdown, redness, and increased pressure. Resident 155’s record showed severe cognitive impairment, dependence for multiple activities of daily living, and lack of capacity to understand and make decisions. The resident also had documented pressure ulcers on the right hip, sacrococcyx, right ankle, and right knee. The facility’s pressure sore management policy directed treatment with all available measures to reduce skin breakdown and pressure sores, and the pressure-reducing mattress policy required a mattress that would prevent or minimize pressure on the skin and ensure proper functioning. For Resident 60, the physician ordered a low air loss mattress for wound care and management and the care plan directed that the mattress be inflated as recommended. During multiple observations, the mattress was not activated and the pump unit’s On light was dim/not lit. An LVN later stated she found the mattress turned off during rounds and turned it on, after which it worked properly. Resident 60 had severe cognitive impairment, was dependent for all ADLs, had a pressure ulcer/injury or related skin condition, and had a Braden score of 14 indicating moderate risk for pressure ulcer development.
Failure to Maintain Floor Mat Safety for Two Residents
Penalty
Summary
The facility failed to ensure the resident environment was free of accident hazards for two residents who had floor mats ordered as fall-injury precautions. Resident 105 had diagnoses including epilepsy, metabolic encephalopathy, and cerebral infarction, and was assessed as severely cognitively impaired, rarely or never able to make self-understood or understand others, and dependent for all ADLs. The resident also had a high fall risk score, a physician order for a floor mat to decrease potential injury, and a care plan calling for a safe and clutter-free environment and use of a lower bed and floor mat. During a concurrent observation and interview, Resident 105's floor mat was seen positioned against the left side wall rather than next to the bed, leaving part of the floor adjacent to the bed uncovered. A waste container and a medical device pole were observed on top of the floor mat. CNA 2 stated the waste container and medical device pole should not be on top of the floor mat. LVN 6 stated nothing should be resting on top of the floor mats because the mats are meant to cushion a resident in the event of a fall, and items on top could prevent the mat from providing cushion and may cause harm or injury during a fall. ADON 1 also stated the floor mat should be placed immediately next to the bed and that items should not be on top of it. Resident 202 had diagnoses including acute respiratory failure, epilepsy, and a history of falling, and was identified as high risk for falls. The resident's MDS indicated a persistent vegetative state and dependence with all ADLs. The resident had an active order for a floor mat to decrease potential injury and a care plan calling for a safe and clutter-free environment. During observation, a floor mat was present on the left side of the bed but not on the right side. ADON 2 verified the right-side floor mat was missing and stated it should be there for the resident's safety in case of a fall. The DON stated Resident 202 should have floor mats as part of safety precautions and that without a floor mat the resident is at risk of injury.
Urinary Catheter Tubing Left Looped With Backflow
Penalty
Summary
The facility failed to ensure that the indwelling urinary catheter tubing for one resident did not have a dependent loop and that urine did not backflow. Resident 212 was admitted with diagnoses including dementia, tracheostomy, and dependence on a ventilator. The Minimum Data Set indicated the resident never or rarely made herself understood and never or rarely understood others, and was dependent for all activities of daily living. During an observation, Resident 212 was found lying in bed asleep with the urinary catheter bag hanging in the middle of the left side of the bed frame. The catheter tubing hung below the left side of the bed and had a large dependent loop containing yellow liquid with a small amount of sediment that back flowed toward the urine drainage port. The Infection Preventionist Nurse stated the tubing was looped and contained yellow liquid with white sediment that back flowed toward the drainage port, and that the tubing should be straight to drain urine into the catheter bag. The ADON stated nursing staff should always ensure urinary catheter tubing remains straight and not coiled or looped to prevent UTIs. The facility policy stated unobstructed flow must be maintained and free of kinks.
GT Not Flushed Before Medication Administration
Penalty
Summary
The facility failed to flush a gastrostomy tube with water before administering crushed medications to one resident, Resident 87, during an observed medication pass. During the observation on 4/21/2026 at 9:45 a.m., LVN 4 was seen preparing to give crushed medication through the resident’s GT without first flushing the tube with water. The surveyor stopped the LVN before any medication was administered and asked to discuss the GT technique. In the concurrent interview, LVN 4 stated that the GT had not been flushed before medication administration. During a later interview on 4/21/2026 at 3:48 p.m., the DON confirmed that LVN 4 failed to flush Resident 87’s GT with water before medication administration. The DON stated that this technique was important to ensure the GT was not clogged and that the resident did not aspirate or need GT replacement. Resident 87’s record showed an admission date of 1/22/2018 and a re-admission on [DATE], with a diagnosis including encounter for attention to gastrostomy. The order summary indicated 30 cc of fluids may be given via GT before and after medication administration, and the facility policy stated the enteral feeding tube should be flushed with at least 30 cc of water before and after medications are administered.
Missing Dialysis Weights on Communication Record
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis services for a resident who required hemodialysis by not ensuring the dialysis center completed the pre- and post-dialysis assessment on the Dialysis Communication Record. For one resident with ESRD and dependence on dialysis, the record for a dialysis treatment showed blank spaces for both the pre-dialysis and post-dialysis weights. The resident’s MDS indicated the resident was cognitively intact, required supervision with eating, and received dialysis treatments. Physician orders directed dialysis on Tuesdays, Thursdays, and Saturdays at a dialysis facility. The resident’s care plan for weight variance, initiated in 2021, included a goal that the resident would not have unrecognized signs and symptoms of fluid overload or dehydration and identified post-dialysis dry weights on the Pre/Post Dialysis Form as an intervention. During interview and record review, the LVN and RN both confirmed the weights were missing from the Dialysis Communication Record. Nursing progress notes did not show that a licensed nurse contacted the dialysis facility for the missing weights, although staff stated the licensed nurse should call the dialysis center to obtain them. The facility policy stated the Dialysis Communication Record should be completed by the dialysis facility nurse and returned with the resident so the facility could complete the post-dialysis assessment.
Failure to Obtain Consent and Order for Four Side Rails
Penalty
Summary
The facility failed to obtain consent and a physician's order for the use of four side rails for Resident 116. Resident 116 was admitted with diagnoses including nontraumatic intracranial hemorrhage, respiratory failure, and hypertensive emergency. The MD progress notes dated 7/9/2025 indicated the resident did not have the capacity to understand and make decisions. The physician's order dated 1/8/2026 directed bilateral upper half siderails up and locked when in bed for ADL changes, and the resident's informed consent dated 7/9/2025 also addressed bilateral upper half side rails up when in bed secondary to involuntary movement by gravity due to elevated head of bed for management and provision of enteral feeding. During observation on 4/20/2026, Resident 116 was seen in bed with upper and lower bed side rails raised on both sides, and later with the left and right upper side rails raised and the right lower side rail raised while CNA 3 stated the resident was supposed to have all four side rails raised up. DSD later stated the resident should only have upper side rails up per the physician's orders. ADON 1 reviewed the informed consent and stated there was no informed consent or physician's order for all four side rails, and that a specific informed consent and physician's order were required for four side rails. The facility policy stated bed rails are prohibited unless criteria are met and that informed consent must be obtained before using bed rails.
Failure to Monitor and Document Apixaban Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation of potential side effects for apixaban for one resident. The resident was admitted on 10/23/2016 and re-admitted on 2/20/2026 with diagnoses including hypertension, chronic respiratory failure, and functional quadriplegia. The MDS dated 2/27/2026 indicated the resident’s cognition was severely impaired for daily decision-making. A physician order summary showed apixaban 2.5 mg twice daily for DVT prophylaxis starting 2/21/2026. During review of the MAR and EMAR, the resident received apixaban from 4/1/2026 through 4/20/2026, but there was no record showing monitoring for side effects of anticoagulant use such as bleeding. The ADON stated apixaban is an anticoagulant that can cause major and serious bleeding and that staff should monitor and document side effects in the EMAR. The DON also stated that side effects of high alert medications should be monitored and documented, and that she could not find documented evidence that staff monitored or assessed for side effects of apixaban. The facility policy titled Anticoagulation - Clinical Protocol stated staff should assess for signs or symptoms of adverse drug reactions and monitor for complications, including bruising, hematuria, hemoptysis, or other evidence of bleeding.
Arbitration Agreement Not Explained in Understandable Manner
Penalty
Summary
The facility failed to ensure the Binding Arbitration Agreement was explained in a manner understandable to Resident 183, despite documentation indicating the resident had the capacity to understand and make decisions. Resident 183’s Face Sheet showed admission from a hospital with diagnoses including osteoporosis, and the MDS described him as moderately cognitively impaired but still able to make daily decisions. The resident signed the arbitration agreement on 4/22/2026, and the H&P dated 4/23/2026 stated he had the capacity to understand and make decisions. During interviews on 4/23/2026, Resident 183 did not recall signing the agreement and gave responses showing limited understanding of the arbitration process, including asking who would be his arbitrator and stating, “Vaguely. My brain is slowly growing back.” The SSD and RN reported periods of confusion, and the AA stated she explains the arbitration process in person if a resident is alert. When asked if he understood the agreement, Resident 183 stated, “No. I just signed it because they wanted me to.” The AA, DON, and ADON were present during the discussion, and the facility’s Question/Answer Arbitration Agreement document described arbitration as a private way to resolve disputes rather than going to court.
Infection Control Failures With Improper Trash Disposal and PPE Noncompliance
Penalty
Summary
The facility failed to maintain infection control measures when a resident’s trash was placed in a bin labeled “URINAL ONLY” that also contained a urinal. Resident 50 had diagnoses including emphysema, history of falls, and muscle weakness, and the record showed the resident had the capacity to understand and make decisions and required supervision for oral hygiene, toileting, upper body hygiene, and personal hygiene. During observation, Resident 50 threw trash into the urinal-only bin, and several items of trash were already inside the bin. Resident 50 stated he did not have another trash bin in the room and would like one. During the same observation, the Assistant Director of Staff Development looked inside the urinal-only bin and stated trash should not be in it because the resident should have a separate trash bin for trash. The Assistant Director of Nursing later stated Resident 50 should have had a separate trash bin for trash only to prevent the spread of germs because it could lead to infection and cross-contamination, and that trash should never have touched the urinal. The facility’s policies on Homelike Environment and Infection Prevention and Control Program stated residents are to be provided a safe, clean, comfortable, and sanitary environment and that the infection prevention and control program is maintained to help prevent the development and transmission of communicable diseases and infections. The facility also failed to ensure a visitor wore required PPE in a shared room where three residents were on contact precautions for CRPA of sputum. Resident 12, Resident 21, and Resident 172 all had diagnoses and assessments showing severe cognitive impairment and dependence for all ADLs, and each had orders and care plans for contact precautions related to CRPA of sputum. During observation, a Stop—Contact Precaution sign was posted at the entrance to the shared room, but a visitor standing by the foot of Resident 172’s bed was not wearing an isolation gown or gloves. A CNA who spoke with the visitor stated the visitor should have been wearing an isolation gown and gloves before entering the room, and stated she did not tell the visitor to do so even though she saw the visitor inside the room without PPE. The ADON stated contact precautions are to be followed by staff and visitors and that staff must explain the precautions to visitors when they do not comply.
Failure to Care Plan for Repeated Refusal of Restorative Nursing Treatment
Penalty
Summary
The facility failed to develop a resident-specific care plan addressing repeated refusals of ordered Restorative Nursing Assistant (RNA) sit-to-stand treatment for a resident with multiple medical conditions and functional impairments. The resident was admitted with diagnoses including acute kidney failure with tubular necrosis, diabetes mellitus, and hypertension, and had a Minimum Data Set indicating moderately impaired cognition and dependence on staff for multiple ADLs such as oral hygiene, toileting, showering, dressing, and personal hygiene. A physician order directed RNA sit-to-stand treatment using a platform walker with a two-person assist five times per week as tolerated, and the existing care plan for risk of further decline in range of motion included this RNA sit-to-stand intervention and therapy as indicated. Record review showed that over a defined period the resident refused the ordered RNA sit-to-stand treatment on multiple specific dates, and staff interviews confirmed that the resident intermittently refused this treatment and that refusals were to be reported to the charge nurse. The LVN stated that when a resident refuses RNA treatment, the nurse is responsible for explaining the importance of the treatment and that a care plan should have been initiated in response to the refusals to help achieve specific resident goals. The DON confirmed that no care plan was initiated related to the resident’s refusal of RNA treatment, despite facility policies requiring a comprehensive, person-centered care plan that includes services not provided due to resident refusal and requiring the IDT to document refusals and develop an alternative program to be added to the care plan.
Unencrypted USB With Resident PHI Lost in Mail
Penalty
Summary
The facility failed to protect the confidential personal and medical information of one resident by copying the resident's complete facility records onto an unencrypted USB drive and mailing it to the resident's family member. The resident had been admitted with diagnoses including malignant neoplasm of the ribs, chronic obstructive respiratory failure, and autistic disorder, and a History and Physical documented that the resident did not have the capacity to understand and make decisions. The resident's authorized representative requested copies of the complete medical record, including medical charts, nursing notes, MARs, physician orders, care plans, incident reports, therapy notes, vital signs, admission/transfer/discharge records, and internal communications related to care. The Medical Records Director attempted to send the requested records via email, but the files were too large, so she saved all requested documents to a USB flash drive that was not password protected or encrypted and mailed it via certified mail to the address provided by the family member. The envelope containing the USB drive was later returned to the facility marked "Return to Sender; Attempted - Not Known Unable to Forward" and was torn open, with the USB drive missing. The Administrator confirmed that the USB drive with the resident's medical records was lost in the mail and that it was not encrypted or password protected, resulting in an unauthorized exposure of the resident's PHI. The information on the USB drive included the resident's Level 1 PASSR screening, insurance eligibility, History and Physical, MD/NP progress notes, all electronic health records (including admission record, MD orders, MAR, nursing progress notes, social services notes, dietary notes, change of condition documentation, IDT meeting notes, and care plans), rehabilitation notes, NOMNC, and copies of the physical paper chart such as consent forms and hospital records. The facility's Privacy Notice policy required the facility by law to maintain the privacy of PHI.
Loss of Unencrypted PHI on USB Drive Due to Lack of Policy
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a policy and procedure governing the use of USB drives for transmitting Protected Health Information (PHI). The governing body was responsible for establishing and implementing policies for managing and operating the facility and for appointing an administrator to manage the facility. The Medical Records Director (MRD) received an email request from a resident’s authorized representative for copies of the resident’s complete medical record. The MRD initially attempted to send the requested records via email, but the files were too large to transmit. The MRD then saved all requested medical record documents onto a USB flash drive and mailed it via certified mail to the address provided by the authorized representative. The USB drive contained the resident’s medical records, medical record number, payor/insurance provider and eligibility information, residency dates at the facility, and share of cost. The facility later received the envelope back marked “Return to Sender; Attempted – Not Known Unable to Forward,” and the envelope was torn open with the USB drive missing. The MRD stated the USB drive was not password protected and confirmed there was no policy or procedure addressing the use of USB drives to send PHI. The Administrator reported that, after learning of the lost unencrypted USB drive, he reviewed the facility’s PHI-related policies and found they were outdated and did not address the use of USB drives or current technology, and acknowledged that if USB drives were being used to send PHI, there should have been a policy requiring password protection.
Failure to Inform Family of Transfer Denial and Provide Discharge Planning Resources
Penalty
Summary
The facility failed to provide required referrals to local agencies and support services for discharge planning and failed to notify a resident’s representative of a denial of admission from a preferred receiving facility. One resident was admitted with malignant neoplasm of the ribs, sternum, and clavicle, along with muscle weakness and difficulty walking. An MDS assessment showed the resident had intact cognition, required setup or clean-up assistance with eating, and was dependent on staff for oral hygiene, toileting hygiene, and personal hygiene. An IDT discharge planning note documented that the resident preferred to return to the community, with a plan to locate an assisted living facility or board and care. During discharge planning, the resident’s family member informed social services staff that she wanted the resident discharged to a facility closer to her home, which was more than three hours away, and she provided the name of a specific facility. The Social Services Director acknowledged receiving this request and documented in the IDT discharge planning record that the plan was to discharge the resident to a facility near the family member. The Social Services Director faxed the resident’s clinical information to the requested facility and received a response the next day indicating that the facility was unable to admit the resident. Despite receiving the denial, the Social Services Director did not inform the family member that the preferred facility had declined admission and did not provide names of other facilities or community resources to assist with identifying alternative placement closer to the family member. The Social Services Director stated that she did not provide additional resources or support for discharge planning and acknowledged that it was her responsibility to do so. The Administrator stated that IDT meetings are used to coordinate necessary services for safe discharge and that the Social Services Director should have assisted the family in finding an appropriate facility closer to them and informed the family of the denial, consistent with the facility’s discharge policy requiring involvement of the resident/representative and referrals to local agencies when there is interest in returning to the community.
Failure to Document Activity Services in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate clinical records for one resident by not documenting activities and room visits as required by policy and accepted professional standards. The resident was admitted with malignant neoplasm of the ribs, sternum, and clavicle, muscle weakness, and difficulty walking, and had intact cognition per the MDS. The MDS also showed the resident required setup or clean-up assistance with eating and was dependent on staff for oral hygiene, toileting hygiene, and personal hygiene. An activity assessment identified the resident’s preferred activities as exercise/sports, watching TV, music stimulation, book tapes, talking/conversing, and spiritual visits, and indicated that recreation staff provided an activity calendar, informed the resident where recreation materials were available, and discussed which groups he might like to attend. A family member reported that the resident remained in bed in his room all day with no activities. The AD stated that each of the four nursing stations had an activity assistant, that activity staff greet residents daily, review the activity calendar, and conduct room visits for residents who do not attend group activities, and that room visits are to be documented in the facility’s computer system. However, upon review of the resident’s documentation survey report for independent activity and room visits, the AD confirmed there was no documented evidence of room visits by activity staff for this resident from admission through the review period. The AD acknowledged that she conducted room visits on the resident’s unit but did not document the activities provided and stated there was no excuse for not documenting, despite facility policies requiring that health services and progress toward care plan goals, as well as changes in the resident’s condition, be documented in the medical record to facilitate communication among the interdisciplinary team.
Non-Functional Call Light Prevents Resident from Requesting Assistance
Penalty
Summary
A deficiency was identified when the call light above a resident's door was found to be non-functional, preventing the resident from alerting staff when assistance was needed. During an observation and interview, it was noted that pressing the call button did not activate the light above the door, as confirmed by a CNA. The Director of Nursing also acknowledged that the call light was not working and should have been repaired to ensure proper notification of staff. The affected resident had been admitted with diagnoses including Parkinson's Disease, spinal stenosis, and elevated white blood cell count. According to the Minimum Data Set, the resident was cognitively impaired and fully dependent on staff for toileting, showering, bathing, personal hygiene, and footwear. Facility policy required regular checks of the call system to ensure functionality, but this was not adhered to in this instance, resulting in the deficiency.
Failure to Maintain Safe and Homelike Environment Due to Damaged Equipment and Fixtures
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents by not repairing or replacing damaged equipment and room fixtures as required. Specifically, one resident with multiple diagnoses including multiple sclerosis, diabetes, and dementia, who was totally dependent on staff for all activities of daily living and had severe cognitive impairment, was found to have a broken wall molding with a piece missing behind their bed. This issue was confirmed by both the DON and the Administrator during observations and interviews, who acknowledged that the damage had not been reported to the Maintenance Department as required by facility policy. Additionally, three other residents with severe cognitive impairments and total dependence on staff for daily activities were found to have bed rails covered with black foam padding that was ripped, gouged, and in poor repair. The exposed porous foam and bed rails were observed during a walk-through with the Subacute Director, who stated that while the padding is changed regularly, there is no set schedule for replacement. The DON confirmed that the damaged padding could potentially harbor bacteria and that all equipment should be in good repair for safety purposes. The facility's own policy and procedure on maintaining a homelike environment, last reviewed in July 2024, requires that residents be provided with a safe, clean, and comfortable environment. Despite this, the facility did not ensure timely repair or replacement of damaged wall molding and bed rail padding, as evidenced by direct observations and staff interviews.
Failure to Assess and Obtain Consent for Bed Rail Use Resulting in Physical Restraint
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints by not performing required assessments and not obtaining proper physician orders prior to the use of bed rails. Specifically, two residents were found with both upper and lower side rails raised on their beds, despite only having consent and physician orders for the use of upper side rails. Facility policy requires a comprehensive assessment, informed consent, and physician order before implementing bed rails, as well as consideration of alternatives and evaluation of potential risks such as entrapment. For one resident, who had diagnoses including metabolic encephalopathy, acute respiratory failure with hypoxia, and congestive heart failure, records showed dependency on staff for all activities of daily living and limited mobility. Although there was informed consent for upper side rails, observations revealed that both upper and one lower side rail were up. Facility leadership confirmed that the lower side rail should not have been raised without proper assessment and consent, as it could be considered a restraint and posed a risk of entrapment. A second resident, admitted with conditions such as adult failure to thrive, dysphagia, and major depressive disorder, also required substantial assistance with daily activities. This resident had a physician's order and informed consent for bilateral upper half side rails only. However, during observation, both upper and one lower side rail were found raised. Staff interviews confirmed that the lower side rail should not have been up and could be dangerous. Review of facility policies reiterated that bed rails are prohibited unless all criteria, including assessment and consent, are met.
Failure to Accurately Assess and Document Resident Needs
Penalty
Summary
The facility failed to ensure accurate and comprehensive assessments for two residents, resulting in deficiencies related to both hearing and mental health diagnoses. For one resident, the Admission Record indicated a diagnosis of schizophrenia, but the Minimum Data Set (MDS) assessments were inconsistently coded. The Admission MDS did not list schizophrenia as an active diagnosis, while subsequent Quarterly MDSs did, despite the resident being in a persistent vegetative state and lacking documentation to support an active diagnosis according to DSM-5 criteria. The MDS Coordinator acknowledged that the Quarterly MDSs were incorrectly coded, as the resident's condition did not meet the criteria for schizophrenia, and the diagnosis was carried over from the hospital without sufficient supporting documentation. Another resident was admitted with multiple diagnoses, including diabetes, heart failure, acute kidney failure, and depression. The MDS assessment indicated the resident had adequate hearing, but the Social Service Hearing Assessment noted impaired hearing and did not recommend hearing appliances or consultation. The resident reported significant difficulty hearing and a prolonged wait for hearing aids, with missed and canceled audiology appointments due to logistical issues. The Social Service Director confirmed that the assessment should have indicated a need for a hearing consultation and that a follow-up assessment was not completed as required. The MDS Coordinator also stated that the resident's hearing should have been coded as moderately impaired rather than adequate. Facility policies required staff to attest to the accuracy of MDS assessments and to assist hearing-impaired residents in obtaining necessary services. However, the assessments for both residents were not completed accurately, and required follow-up actions, such as timely hearing assessments and proper documentation of mental health diagnoses, were not performed. These failures resulted in inaccurate depictions of the residents' needs and affected their care plans.
Failure to Develop and Implement Comprehensive Care Plans for Pressure Ulcer and Diet Change
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to both pressure ulcer management and dietary changes. For one resident with type 2 diabetes, generalized muscle weakness, reduced mobility, and moderately impaired cognition, the facility did not create a care plan addressing a stage II pressure ulcer on the sacrococcyx, despite physician orders for daily wound care. The Minimum Data Set Coordinator confirmed that no care plan was in place for the pressure ulcer or its treatment, and the Director of Nursing acknowledged that this omission could result in the resident not receiving proper care. Another resident, admitted with diffuse traumatic brain injury, gastrostomy, and tracheostomy, experienced a significant change in diet order from a twice-daily pureed diet to three daily meals of regular mechanical soft texture. Staff interviews revealed that both a Certified Nursing Assistant and a Registered Nurse were unaware of the new diet order, and the care plan had not been updated to reflect the change. The Director of Nursing confirmed that care plans should be revised as residents' conditions change, but this was not done in this case. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan within specified timeframes, including measurable objectives and timeframes, and to revise care plans as residents' conditions change. In both cases, the lack of updated care plans meant that staff were not properly guided in providing necessary care and services for the residents' current needs.
Failure to Provide Timely Audiology Services for Hearing-Impaired Resident
Penalty
Summary
A resident with multiple medical conditions, including diabetes, heart failure, acute kidney failure, and depression, was admitted to the facility and had a documented need for hearing support. The resident's records included an active order for an audiology consult as needed for hearing problems. Despite this, the resident reported ongoing difficulty hearing and stated he had been waiting approximately six months for hearing aids. He also described a missed appointment with an ear doctor due to lateness and subsequent unfulfilled promises of an in-facility evaluation. The resident expressed that his hearing impairment made it very difficult to enjoy his favorite activity, watching TV. Facility documentation showed that a Social Service Assessment (Hearing) was completed, but it indicated that hearing appliances and consultation were not needed, contrary to the resident's ongoing complaints and the ENT's recommendation for an audiology exam for hearing aids. Attempts to schedule audiology appointments were unsuccessful due to the audiology office's inability to accommodate a gurney, and no in-house audiology services were available. The Social Service Director acknowledged that the assessment should have indicated a need for a hearing consultation and that a follow-up assessment was not completed as required. Facility policy required staff to assist hearing-impaired residents in accessing needed services, but this was not effectively carried out for this resident.
Failure to Implement Fall and Injury Prevention Interventions
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision and implementation of safety interventions for multiple residents at high risk for falls and injury. For one resident with metabolic encephalopathy, legal blindness, and a history of falling, the physician ordered floor mats to be placed at the bedside to reduce injury risk. However, observations on multiple occasions revealed that no floor mats were present, and staff confirmed the absence of this intervention despite the resident's high fall risk. The Director of Nursing acknowledged that not providing the prescribed floor mats could potentially result in injury if a fall occurred. Another resident with a history of falling, muscle weakness, and seizures was also ordered to have floor mats on both sides of the bed. Despite this, observations and staff interviews confirmed that no floor mats were present at the bedside. The care plan for this resident included the use of floor mats as a fall prevention measure, but this intervention was not implemented. The Director of Nursing confirmed the omission and recognized the increased risk of injury due to the lack of floor mats. Additionally, a resident with severe cognitive impairment and total dependence on staff had a physician's order and care plan for padded bed rails to prevent injury. During observation, the bed rail padding was found to be ripped, exposing the hard bed rail, and staff acknowledged that this would not protect the resident from injury. Another resident with a history of falls and seizures had incomplete and inaccurate fall risk assessments, with missing documentation of predisposing factors and recent falls. The Director of Nursing confirmed the importance of accurate assessments for effective care. Facility policies reviewed indicated that staff are required to implement and monitor interventions to prevent falls and injuries, but these were not consistently followed.
Failure to Reconcile Controlled Medications in Emergency Kits
Penalty
Summary
The facility failed to reconcile controlled medications (CMs) in emergency medication kits (eKITs) at every shift in two separate locations: Medication Room Station 1 and Medication Cart Station 2B. During observations and interviews, it was found that the eKIT labeled 109 in Medication Room Station 1 and the eKIT labeled 318 in Medication Cart Station 2B, both containing CMs, did not have accountability logs documenting reconciliation of CM inventory for the month of May 2025. Registered and vocational nursing staff confirmed that these eKITs were not reconciled at every shift, as required, and acknowledged the importance of this process for accountability and prevention of CM diversion or accidental exposure. A review of the facility's policy and procedure on controlled medication storage indicated that all CMs, including those in emergency supplies, must be physically inventoried by two licensed nurses and documented at each shift change. Despite this policy, the required reconciliation and documentation were not performed for the identified eKITs in the specified medication room and cart, resulting in a lack of compliance with federal and state regulations regarding the handling of controlled substances.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with two medication errors identified out of 34 opportunities, resulting in an 8.82% error rate. One error involved a nurse administering carvedilol to a resident with hypertension at a time inconsistent with the physician's order, which specified administration at 8 a.m. with food. The nurse acknowledged administering the medication outside the facility's 60-minute window for scheduled medications, as outlined in facility policy, and recognized this as a medication error. Another resident, who had diagnoses including malnutrition and failure to thrive, did not receive docusate as ordered and was given a multivitamin with minerals instead of the prescribed multivitamin without minerals. The nurse responsible stated that docusate was withheld due to a soft stool, despite the order specifying to hold only for loose stools, and admitted this was an error. The nurse also acknowledged administering the incorrect form of multivitamin, contrary to the physician's order. Interviews with the Director of Nursing confirmed that these incidents were considered medication errors according to facility policy and procedures. Documentation review supported that the medications were not administered as prescribed, and the facility's policies require strict adherence to physician orders and scheduled administration times.
Improper Storage and Failure to Discard Expired Medications
Penalty
Summary
Surveyors identified that the facility failed to properly remove and discard expired or improperly stored medications, including insulin and Procrit, in accordance with manufacturer requirements and facility policies. Specifically, an opened insulin Aspart Flexpen for one resident was found stored in the refrigerator with a label indicating it had expired after 28 days, but it was not removed from use. Another instance involved an opened Humulin R insulin vial for a different resident, which was stored in the refrigerator without a label indicating when it was first opened, contrary to manufacturer instructions that require room temperature storage and use within 31 days of opening. Additionally, a single-dose vial of Procrit for another resident was found in the refrigerator with unused medication remaining, despite manufacturer and facility policy requiring immediate disposal after initial use. Interviews with nursing staff and the Director of Nursing confirmed that these medications were not handled according to policy, with staff acknowledging that expired or unlabeled medications should have been removed and disposed of to prevent accidental administration. Facility policy reviews corroborated the requirement for medications to be labeled with open dates, stored according to manufacturer guidelines, and discarded after specified periods or after single use. The observed deficiencies were limited to the improper storage, labeling, and failure to discard expired or used medications, as directly evidenced by the surveyor's findings and staff interviews.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was prepared and served at safe and appetizing temperatures, as required by their policies and procedures. Observations during meal service revealed that hot foods, such as zesty spinach, were served at 121°F, which is below the required minimum of 135°F, and cold foods, such as chocolate cake and milk, were served at temperatures ranging from 47°F to 60°F, exceeding the maximum allowable temperature of 40°F for cold items. Staff were observed not consistently taking or recording food temperatures, and some items, like spinach, were placed directly into serving pans without temperature checks. Additionally, cold items such as green salad, chocolate cake, and milk were left at room temperature for extended periods before service. Interviews with dietary staff and supervisors confirmed awareness of the facility's standards for food temperatures and the importance of maintaining hot foods above 135°F and cold foods below 41°F. Staff acknowledged that the observed food temperatures did not meet these standards and that proper temperature checks were not always performed. The facility's own policies emphasized the need for food to be prepared and served at appropriate temperatures to preserve flavor, appearance, and safety, but these procedures were not consistently followed, placing a significant number of residents at risk.
Failure to Prepare Pureed Foods to Required Consistency
Penalty
Summary
The facility failed to prepare pureed foods in a form designed to meet the individual needs of residents on a pureed diet. During observation of meal preparation, staff were seen adding potato flakes to pureed pasta without measuring, relying instead on visual assessment and a spoon tilt test. When the pureed pasta was evaluated by the Dietary Supervisor and Registered Dietitian, it was found to contain small pasta particles and to be sticky, rather than smooth and pudding-like as required. The Dietary Supervisor confirmed that the sticky consistency would require more chewing and could pose a problem for residents with chewing and swallowing difficulties. The facility's policies, diet manual, and standardized recipes all specify that pureed foods should be smooth, moist, and free of lumps, and that recipes should be followed with correct ingredient measurements to achieve the proper texture and consistency. Eighteen residents on pureed diets were potentially affected by this failure, as the pureed pasta did not meet the required standards for texture and consistency. The facility's menu, policies, and IDDSI guidelines all require that pureed foods be smooth, not sticky, and pass specific consistency tests, but these standards were not met during the observed meal preparation. The deficiency was identified through direct observation, interviews with dietary staff, and review of facility documentation.
Widespread Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as evidenced by multiple observations of improper food handling and unsanitary conditions. Opened bags of frozen pancakes and pie crusts were found in the freezer without labels or dates, contrary to facility policy and food code requirements. Additionally, several areas and pieces of kitchen equipment, including the reach-in refrigerator, drawers, plate warmer, push carts, and condiment containers, were observed to have dust, dirt, food debris, and hair, indicating a lack of proper cleaning and sanitization. Staff interviews confirmed that cleaning schedules were not consistently followed, and these areas were not cleaned as required. Further deficiencies were noted in the maintenance of kitchen equipment and utensils. All green shelves in the walk-in refrigerators were found to have cracks, chips, and rust, while the chopping board and juice rack were stained, scratched, and rusted, making them difficult to clean and sanitize. Staff members were observed wearing jewelry, including wristwatches, bracelets, and a diamond ring, as well as nail polish while preparing food, which is prohibited by both facility policy and food safety codes. Dented cans were stored with non-dented cans, and food containers, plates, and trays were stacked while still wet, rather than being air-dried as required. There was also a lack of separation between clean and dirty areas, with a trash can placed near the bowl storage area and water splashes observed from the handwashing area to the clean storage area. Additionally, a resident's freezer was found to have no thermometer, and there was no evidence that freezer temperatures were being monitored or logged. These failures were observed during kitchen tours and interviews with dietary staff and supervisors, who acknowledged the lapses and the importance of adhering to proper food safety and sanitation protocols.
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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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