California Home For The Aged
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 6720 E. Kings Canyon, Fresno, California 93727
- CMS Provider Number
- 055955
- Inspections on file
- 19
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at California Home For The Aged during CMS and state inspections, most recent first.
A deficiency was cited for not ensuring an area was free from accident hazards and for failing to provide adequate supervision to prevent accidents. The environment contained hazards and supervision was insufficient to prevent incidents.
Surveyors found that the facility's sprinkler system was not properly maintained, with missing signage on inspector test valves, a dust-covered sprinkler, and a delayed waterflow alarm activation. Staff were unaware of these issues, which affected all residents in the building.
The facility did not conduct fire drills at varying times as required, instead holding drills at the same times for both AM and PM shifts. Staff were unaware that repeating drill times was not permitted, resulting in noncompliance with fire safety regulations affecting all residents.
A corridor door was found obstructed by a floor mat, preventing it from closing properly. This issue was observed during a facility tour and confirmed by staff, affecting multiple residents and a smoke compartment.
Surveyors found that two electrical panels in mechanical rooms had several circuits missing required identifiers, with staff either unaware of their purpose or identifying them as spares. This failure to label circuits affected a portion of the facility and did not comply with NFPA 70 standards.
Surveyors observed the use of extension cords in both a staff office and a resident room, with one cord powering a coffee machine and another used for phone charging. Staff were unaware of the prohibition on extension cords, and one cord had been brought in by a resident. These findings affected multiple residents and a smoke compartment.
A resident's care plan failed to include duloxetine hydrochloride, a psychotropic medication prescribed for anxiety disorder, despite being admitted with active orders for it. The care plan only addressed trazodone and buspirone, omitting duloxetine. Facility staff, including LVNs and the DON, confirmed the oversight, acknowledging that the IDT was responsible for ensuring all medications were included in the care plan.
A resident received medications not prescribed for her due to a failure by an LVN to verify the correct patient before administration. The LVN did not adhere to the facility's medication administration policy, which requires following the five rights of medication administration. The error was confirmed by the DON, who noted the LVN's failure to follow professional standards and facility procedures.
The facility failed to provide a comfortable homelike environment for three residents when the air vents in their rooms were observed to be covered with black and brown stains and dust. Residents and staff expressed discomfort and dissatisfaction with the cleanliness of the vents, and the Infection Preventionist highlighted the potential health risks for residents with respiratory issues. Despite facility policies emphasizing cleanliness, the air vents were not adequately maintained.
The facility failed to develop and implement comprehensive care plans for four residents, including the use of side rails, respiratory treatments, special mattresses, and urinary catheter monitoring. This lack of care planning placed the residents at risk of injury and infection.
The facility failed to meet professional standards for four residents. An RN signed the eMAR before administering medications and improperly applied a lidocaine patch. An LVN administered Potassium Chloride without food. Another resident received incorrect oxygen flow and had an unchanged humidifier bottle. A fourth resident's humidifier bottle was not changed as required, and their nasal cannula tubing was unlabeled.
The facility failed to ensure the medication error rate did not exceed five percent. An RN did not administer metoprolol to a resident due to unavailability, and an LVN did not follow instructions to administer potassium chloride with breakfast. These errors resulted in a calculated medication error rate of 7.69 percent.
The facility failed to ensure proper storage and labeling of medications. A resident's narcotics were repacked in unlabeled plastic bags, and two boxes of omeprazole lacked received and expiration dates. Staff were unaware of the proper procedures, and the DON confirmed these practices were against facility policy.
The facility failed to provide a well-balanced diet to several residents by continuing discontinued supplements and providing chopped diets without physician orders. This was due to poor communication between nursing staff and the kitchen, as evidenced by discrepancies in tray tickets and official dietary orders.
The facility failed to follow the prescribed small portion diet for two residents, using a #16 scoop instead of the required #12 scoop for Spanish rice. This discrepancy was confirmed by the Dietary Service Supervisor and the Registered Dietitian, potentially compromising the residents' caloric intake and medical status.
The facility failed to ensure food was prepared in accordance with professional standards for food service safety when a cook did not wear a beard restraint while preparing food, potentially leading to contamination.
The facility failed to ensure medical records were complete and accurately documented. One resident's humidifier bottle change was not recorded correctly, and four residents had incomplete POLST forms, lacking essential information such as the physician's phone number and license number. These deficiencies pose risks to residents' health and their ability to have their treatment preferences respected.
The facility failed to implement safe infection control measures for two residents, as their urinary catheter tubing and drainage bags were observed lying on the floor. Staff confirmed that this practice posed a risk of infection and did not adhere to the facility's policies on urinary catheter care and infection control.
The facility failed to ensure that LNs, CNAs, and ancillary support staff completed mandatory in-service training for dementia care, fall prevention, and abuse prevention. A significant portion of the staff did not attend these essential training sessions, potentially placing residents at risk for inadequate care.
The facility failed to ensure residents were treated with dignity and respect when two residents' urinary catheter bags were not placed in dignity bags, making them visible from the hall. Staff confirmed this was against the facility's policy, which requires catheter bags to be covered to protect residents' dignity.
The facility failed to ensure the MDS assessment accurately reflected a resident's health and functional status. The resident, with a history of hemiplegia and muscle weakness, was inaccurately coded as having no impairment in the upper extremity. Interviews confirmed the resident required assistance with ADLs due to limited mobility in the left arm. The MDSRN admitted to the error, and the DON confirmed the resident should have been coded for upper extremity weakness.
The facility failed to complete a PASRR assessment for a resident diagnosed with major depressive disorder, dementia, and psychotic disorder who was started on psychotropic medications. The admission coordinator and Director of Nursing acknowledged the oversight, and the facility lacked a specific PASRR policy.
The facility failed to validate the competency of the Infection Preventionist (IP) after hiring, as confirmed by the DON and DSD. The IP, responsible for infection prevention and control, did not have her nurse competency checked, contrary to facility policy, potentially risking infection spread among residents.
The facility failed to provide pharmaceutical services for a resident when their metoprolol medication was not available for administration. The resident's blood pressure was elevated, and the nurse had to notify the physician about the unavailability. Interviews revealed that licensed nurses are responsible for ensuring medication availability, and the facility's policies emphasize the importance of notifying the prescriber and following up with the pharmacy.
The facility failed to maintain adequate lighting in one of its medication rooms, where only one of four fluorescent lights was working. This issue persisted for at least two months, making it difficult for staff to read medication labels and increasing the risk of tripping. The Maintenance Facility Director was unaware of the problem until the survey, and the administrator did not consider it an immediate hazard.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could lead to accidents, and that supervision was not sufficient to prevent such incidents. Specific actions or inactions leading to this deficiency include the presence of accident hazards and a lack of appropriate oversight in the area in question. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Sprinkler System Maintenance and Testing Deficiencies
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 13 standards. During a tour and interviews with staff, surveyors observed that inspector test valves (ITVs) in the medicine room by nurses station 3 and in the courtyard were missing required signage. Staff interviewed were unaware of the missing signs. Additionally, a sprinkler located in the storage closet next to nurses station 3 was found to be covered in dust, and staff were not aware of this condition. Further, when the waterflow was tested at the ITV in the medicine room by nurses station 3, it took 116 seconds for the alarm to initiate after the valve was fully opened, which exceeds the acceptable time for waterflow alarm activation. Staff interviewed were unaware of the reason for this delay. These deficiencies affected all 103 residents in the facility across five smoke compartments.
Plan Of Correction
K 353: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? The facility has not identified any residents affected by the deficient practice but recognizes that all residents have the potential to be affected. The facility contracted with MS Fire, a qualified contractor, to inspect each identified area of deficiency, and to determine and obtain the necessary signage for each Inspector Test Valve and all Auxiliary Drain valves. During this inspection, the valve located in the medicine room by station 3 was properly identified as an Auxiliary Drain Valve and not an Inspector Test Valve. Signage indicating that this is an Auxiliary Drain valve was placed during the inspection done on 04/02/2025. As this was identified as an Auxiliary Drain valve and not an Inspector Test Valve, MS Fire has corroborated during their inspection that the water flow expected of this valve was in working order and it is not expected to perform as an Inspector Test Valve, alarming in no more than 90 seconds. This is because Auxiliary Drain valves do not have the restricted head on the discharge pipe to correctly stimulate a fire sprinkler activation as an Inspector Test Valve would, and therefore this is why it took longer than 90 seconds to alarm. During this same inspection, the valve located in the courtyard was properly identified as an Auxiliary Drain Valve and not an Inspector Test Valve. Signage indicating that this is an Auxiliary Drain Valve was placed during the inspection done on 04/02/2025. Two other correctly identified Inspector Test Valves were tested during the survey process and performed within regulatory requirements, alarming in less than 90 seconds. The sprinkler located in the storage closet next to Nurses Station 3 was cleaned of dust on 3/26/25 by the Maintenance Lead and reinspected by MS Fire on 04/02/2025. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility recognizes that while no residents were identified to have been affected by the deficient practice, all residents have the potential to be affected. The same corrective actions as listed above are the corrective actions taken to eliminate the potential risk to the residents. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? The Maintenance Director in-serviced all maintenance personnel on the locations and appropriate signage required for Inspector Test Valves and Auxiliary Drain valves. Also included in this same in-service was the importance of inspecting and cleaning sprinkler heads to keep them free of dust. The facility utilizes TELS Building Management System for all Maintenance related inspections or tasks. A monthly in-house fire sprinkler inspection task was added to the Maintenance TELS system to include checking fire sprinkler heads for dust and Auxiliary Drain Valves and Inspector Test Valves for appropriate signage. Any findings will be immediately corrected and reported by the Maintenance team member completing the task to the Maintenance Lead and/or Director. Housekeeping staff was in-serviced by the Hospitality Director/Environmental Services Director on how to clean fire sprinkler heads to keep them free of dust. How does the facility plan to monitor its performance to make sure that the corrective actions are implemented and achieved, the solutions are sustained, and that the corrective actions taken are evaluated for effectiveness through integrations into the facility's Quality Assurance system? The Facility Maintenance Director shall review monthly in-house sprinkler inspection task reports for completion and findings. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? The Maintenance Director in-serviced all maintenance personnel on the locations and appropriate signage required for Inspector Test Valves and Auxiliary Drain valves. Also included in this same in-service was the importance of inspecting and cleaning sprinkler heads to keep them free of dust. The facility utilizes TELS Building Management System for all Maintenance related inspections or tasks. A monthly in-house fire sprinkler inspection task was added to the Maintenance TELS system to include checking fire sprinkler heads for dust and Auxiliary Drain Valves and Inspector Test Valves for appropriate signage. Any findings will be immediately corrected and reported by the Maintenance team member completing the task to the Maintenance Lead and/or Director. Housekeeping staff was in-serviced by the Hospitality Director/Environmental Services Director on how to clean fire sprinkler heads to keep them free of dust.
Failure to Conduct Fire Drills at Varying Times
Penalty
Summary
The facility failed to maintain proper fire drill procedures as required by NFPA 101. Record review and staff interviews revealed that fire drills were repeatedly conducted at the same times for both AM and PM shifts, rather than at varying times as required. Specifically, AM shift fire drills on three separate dates were all conducted at 10 a.m., and PM shift drills on two dates were both conducted at 3 p.m. Staff confirmed they were unaware that fire drill times could not be repeated. This deficiency affected all 103 residents across all five smoke compartments.
Plan Of Correction
K 712: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? No residents were identified to have been affected by the deficient practice. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? No other residents were identified to have been affected by the deficient practice, but the facility recognizes that all residents have the potential to be affected by the deficient practice. To gain compliance, two fire drills were conducted on the AM and PM shifts at times different than previously completed. A fire drill was conducted on 04/03/2025 at 7:00 am and on 04/04/2025 at 6:30 pm. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? The Facilities Maintenance Director in-serviced all Maintenance staff that conduct fire drills of the requirements that such drills are to be held at expected and unexpected times, under varying conditions, at least quarterly on each shift. The Facilities Maintenance Director added a monthly fire drill task to the TELS system so that the Maintenance team can conduct such drills at unexpected and varying times on all shifts quarterly. The Maintenance Director and/or Maintenance Lead will be responsible for ensuring the time of the in-service is appropriate.
Corridor Door Obstructed by Floor Mat
Penalty
Summary
During a facility tour, surveyors observed that the corridor door to resident room 507 was obstructed by a brown floor mat placed by bed A. This obstruction prevented the door from closing properly. The presence of the mat was confirmed during an interview with a staff member, who acknowledged that the door mat was in the way. This deficiency affected 23 out of 103 residents and one of five smoke compartments in the facility. The failure to maintain the corridor doors in accordance with regulatory requirements was specifically evidenced by the inability of the door to close due to the obstruction, as directly observed and confirmed by staff.
Plan Of Correction
K 363 and/or findings shall be reported by the Maintenance Director to the Quality Assurance and Performance Improvement Committee monthly for integration and recommendations. K 363: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? The mat that prevented the door of room 507 from closing was immediately relocated by the Maintenance Lead to allow the door to fully close. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility did not identify any other residents affected by the deficient practice but recognizes any resident in the first bed of the room with a floor mat has the potential to be affected by this same deficient practice. On 3/26/2025, all residents with floor mats were identified and all rooms were inspected to ensure that none of those mats impeded or obstructed the door from closing. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? An in-service by the Director of Staff Development was held for all staff about ensuring that nothing, including floor mats, can prevent the resident room door from closing. The facility's Maintenance Director added a monthly corridor door inspection task to the TELS system, so the maintenance department is instructed to inspect all corridor doors monthly for proper closing and to ensure they are free from obstruction. Any findings shall be corrected immediately. NEXT PAGE INTENTIONALLY BLANK DUE TO FORMATTING. THIS PAGE INTENTIONALLY LEFT BLANK DUE TO FORMATTING. How does the facility plan to monitor its performance to make sure that the corrections are implemented and achieved, the solutions are sustained, and that the corrective actions taken are evaluated for effectiveness through integration into the facility's Quality Assurance system? The Facilities Maintenance Director will review the monthly corridor door inspection reports in TELS and report compliance and any findings to the Quality Assurance Committee monthly for integration and recommendations.
Electrical Panel Circuits Missing Required Identification
Penalty
Summary
Surveyors observed that the facility failed to maintain proper identification of electrical circuits in two separate electrical panels located in mechanical rooms. Specifically, Panel A was found to have two out of forty-two circuits (circuits 13 and 27) missing identifiers, and Panel F had three out of forty-two circuits (circuits 26, 28, and 30) without labels. During interviews, staff indicated that the unlabeled circuits in Panel A were considered spares, while for Panel F, staff were unaware of the purpose of the unlabeled circuits. These deficiencies were identified during a facility tour and staff interviews, affecting 23 of 103 residents in one of five smoke compartments. The lack of proper labeling on the electrical panels was found to be non-compliant with NFPA 70 National Electrical Code requirements, which mandate that each circuit be clearly and legibly identified as to its specific purpose or use.
Plan Of Correction
How does the facility plan to monitor its performance to make sure that the corrections are implemented and achieved, that solutions are sustained, and that the corrective actions taken are evaluated for effectiveness through integration into the facility's Quality Assurance system? The Facilities Maintenance Director will review the monthly fire drill reports to ensure compliance with varying times and shift compliance. Any findings will be corrected within the month by way of a separate drill if required. The Facilities Maintenance Director will report compliance and findings of fire drills to the Quality Assurance Committee monthly for 12 months for integration and recommendations if indicated. K 919: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? No residents were found to be affected by the deficient practice in regard to the unlabeled circuits. The Maintenance Lead inspected and identified that circuits 13 and 27 in Panel A and confirmed them to be "spares". They were correctly labeled as "SPARE" on 03/27/2025. The maintenance lead inspected and identified that circuits 26, 28, and 30 on Panel F and confirmed them to be "spares". They were correctly labeled as "SPARE" on 03/27/2025. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? No other residents were found to have been affected by the deficient practice and the corrective action taken above ensures that no residents will be affected. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? The Facilities Maintenance Director in-serviced all Maintenance Personnel in regard to the requirements of K919, specifically ensuring all circuit breakers are labeled. The Facility Maintenance Lead will inspect the electrical panels for proper circuit labeling monthly for three months. After this, the Facilities Maintenance Director added an annual "Inspect and Document the Main and Feeder Circuit Breakers" task to the TELS system to
Improper Use of Extension Cords in Staff and Resident Areas
Penalty
Summary
The facility failed to maintain electrical equipment in accordance with regulatory requirements, as evidenced by the use of extension cords in both a staff area and a resident room. During a facility tour, surveyors observed an orange extension cord plugged into a coffee machine in the medical records office. Staff interviewed at the time indicated they were unaware that the use of extension cords was not permitted. Additionally, a brown extension cord was found in a resident room, being used to charge a phone. Staff reported that the extension cord had been brought in by the resident. These observations affected 23 of 103 residents and one of five smoke compartments within the facility.
Plan Of Correction
Ensure the Maintenance Department is inspecting all electrical breaker panels annually for appropriate and proper labeling. How does the facility plan to monitor its performance to make sure that the corrections are implemented and achieved, that solutions are sustained, and that the corrective actions taken are evaluated for effectiveness through integration into the facility's Quality Assurance system? The Facilities Maintenance Director will review the monthly inspections by the Facilities Maintenance lead and report findings and compliance to the Quality Assurance committee monthly for three months for integration and recommendations, and then annually thereafter. K 920: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? The extension cord in room 503 and in the Medical Records office were immediately removed by the Maintenance Lead. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility has not identified any other residents affected by the deficient practice. An inspection walk-through of all patient rooms and non-patient rooms was conducted on 03/27/2025 to ensure no other extension cords were in use. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? Maintenance staff were in-serviced by the Facilities Maintenance Director on 4/4/2025 to review K 920 findings and the acceptable and appropriate use of extension cords and/or power strips. An in-service for all staff was conducted by the Director of Staff Development and Maintenance Lead to educate staff that extension cords are not permitted to be used except for temporary purposes and must be removed immediately upon completion of the task for which it was used. Staff were educated to be observant for unauthorized use of extension cords and to remove them immediately, and to report any use of power strips to Maintenance so that Maintenance can ensure the power strip is compliant in its use and design. The Facilities Maintenance Director generated a monthly Room Safety Inspection task within the TELS system so that the Maintenance department can inspect all rooms for use of extension cords and/or power strips monthly. Findings shall be corrected immediately. The Facilities Maintenance Director will review the monthly Room Safety Inspection task reports from TELS for compliance and findings and shall report compliance and findings monthly for three months to the Quality Assurance Committee for integration and recommendations if indicated.
Omission of Psychotropic Medication in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a psychotropic medication, duloxetine hydrochloride, was addressed on the comprehensive care plan for a resident with a history of major depressive disorder, anxiety disorder, and insomnia. The resident was admitted to the facility with active orders for duloxetine hydrochloride for anxiety disorder and trazodone hydrochloride for major depressive disorder. However, the care plan only addressed trazodone and another anti-anxiety medication, buspirone, but omitted duloxetine. This oversight was identified during a review of the resident's care plan and confirmed by multiple staff members, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON). Interviews with facility staff revealed that the responsibility for updating and revising care plans fell to the floor nurses, with the admission nurse responsible for ensuring new medication orders were addressed in the care plan. Despite this, duloxetine was not included in the care plan, which was acknowledged by the DON and the Director of Social Services (DSS). The Administrator also confirmed that the interdisciplinary team (IDT) was responsible for the comprehensive care plan and expected duloxetine to be included, given its classification and use. The omission of duloxetine from the care plan was a clear deficiency in the facility's adherence to its policy of developing comprehensive, person-centered care plans that include all prescribed medications.
Medication Administration Error Due to Non-Compliance with Verification Protocols
Penalty
Summary
The facility failed to ensure that licensed nurses administered medications in accordance with professional standards of practice, resulting in a medication error for one resident. The incident involved a resident who was administered medications that were not prescribed for her. The resident, who had no cognitive impairment as indicated by a Brief Interview for Mental Status score of 13, was given several medications not listed in her physician's orders, including pantoprazole, carvedilol, potassium phosphate, amlodipine, memantine, and pioglitazone. This error occurred because the Licensed Vocational Nurse (LVN) responsible for administering the medications did not verify the correct patient before administration, relying instead on a picture in the medication administration software. During the investigation, the LVN admitted to not following the facility's policies and procedures, which require verification of the correct patient and adherence to the five rights of medication administration: the right patient, the right drug, the right time, the right dose, and the right route. The Director of Nurses confirmed the error and stated that the LVN did not follow the facility's medication administration policy. The facility's policy, dated April 2019, emphasizes the importance of administering medications according to prescriber orders and documenting any medication errors. The report highlights the potential risk for adverse drug effects due to this medication error.
Failure to Maintain Clean Air Vents
Penalty
Summary
The facility failed to provide a comfortable homelike environment for three residents when the air vents in their rooms were observed to be covered with black and brown stains and dust. During observations and interviews, residents expressed discomfort and dissatisfaction with the cleanliness of the air vents, stating that they would not tolerate such conditions in their own homes. Certified Nursing Assistants (CNAs) and other staff members also acknowledged the dirty condition of the vents and agreed that they did not promote a homelike environment. The Infection Preventionist (IP) highlighted the importance of maintaining clean air vents, especially for residents with respiratory issues such as pneumonia, chronic obstructive pulmonary disease (COPD), and asthma. The IP stated that dirty air vents could lead to residents breathing in contaminated air, potentially causing respiratory distress. The Director of Hospitality (DOH) and the Maintenance Lead (ML) confirmed that housekeeping staff were responsible for cleaning the vents and that unclean vents should be either cleaned, repainted, or replaced to ensure a comfortable living environment for residents. The facility's policies and procedures emphasized the importance of providing a clean, sanitary, and homelike environment for residents. The Housekeeping Department was responsible for maintaining high infection control standards and ensuring that the facility complied with all relevant regulations. Despite these policies, the observations and interviews revealed that the air vents in the residents' rooms were not adequately cleaned, leading to an uncomfortable and potentially unhealthy living environment.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents. For Residents 49 and 80, there were no individualized care plans developed for the use of side rails, despite having signed consent forms and physician orders. This oversight was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who acknowledged that the care plans should have included interventions such as bed inspections and frequent visual checks to prevent risks of entrapment and injury. Resident 37 had an order for ipratropium bromide via a hand-held nebulizer for respiratory illness, but there was no care plan developed to educate the resident on its use. Additionally, Resident 37 was using a low air loss mattress to prevent skin breakdown, but again, no care plan was developed for this intervention. The Licensed Vocational Nurse (LVN) and the DON confirmed that care plans should have been initiated when the orders were received to guide the nursing staff in providing appropriate care. For Resident 4, the facility failed to implement a person-centered care plan for urinary catheter monitoring. The resident's catheter tubing was observed touching the floor, which could lead to infection. The ADON and other staff members confirmed that there were no documented orders for catheter monitoring, and the care plan did not include necessary interventions. This lack of documentation and monitoring placed Resident 4 at an increased risk of developing a urinary tract infection.
Failure to Adhere to Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to meet professional standards of practice for four of twelve sampled residents. For Resident 25, a Registered Nurse (RN) signed the electronic Medication Administration Record (eMAR) prior to administering medications, resulting in inaccurate charting. Additionally, the same RN did not follow medication administration directions when applying a lidocaine patch to Resident 25's left upper arm without cleaning the site, potentially affecting medication absorption and causing skin irritation. Resident 25 was admitted with diagnoses including hypertension, muscle weakness, and chronic pain. For Resident 55, a Licensed Vocational Nurse (LVN) administered Potassium Chloride without food, contrary to the medication's directions, which could lead to stomach upset and affect medication absorption. Resident 55 had diagnoses of hypokalemia, hypertension, and muscle weakness. In the case of Resident 52, the oxygen flow rate was set to 3 liters per minute (L/min) instead of the ordered 4 L/min, potentially causing shortness of breath and respiratory distress. Additionally, Resident 52's humidifier bottle was not changed for six days, risking bacterial growth and inadequate humidification of the oxygen being delivered. Resident 66's humidifier bottle was not changed every three days as required, which could lead to dry mucosal membranes and associated complications. Furthermore, the nasal cannula tubing for Resident 66 was not labeled with the date it was opened, risking contamination and infection. Resident 66 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). These deficiencies were observed through a combination of direct observation, interviews with staff, and record reviews, highlighting a failure to adhere to professional standards and facility policies for medication and treatment administration.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed five percent. Registered Nurse (RN) 1 did not administer metoprolol to Resident 25 because it was not available. This medication was prescribed to manage Resident 25's high blood pressure and pulse. At the time of the observation, Resident 25's blood pressure was 150/85 and pulse was 85. The failure to administer the medication as prescribed had the potential to cause serious health conditions. The Director of Nursing (DON) confirmed that it was the responsibility of licensed nurses to ensure medications were available and administered as ordered. Licensed Vocational Nurse (LVN) 4 did not follow the medication label instructions to administer potassium chloride with breakfast for Resident 55. Instead, the medication was given while Resident 55 was lying in bed with eyes closed and breakfast untouched. This failure could lead to stomach irritation and affect the medication's effectiveness. The DON stated that medications with specific instructions to be taken with food should be administered while the resident is actively eating to prevent adverse effects. The facility's policies and procedures were reviewed, indicating that medication errors include omissions and failure to follow manufacturer's instructions. The calculated medication error rate was 7.69 percent, exceeding the acceptable threshold of five percent. Interviews with staff and the DON highlighted the importance of adhering to medication administration protocols to prevent serious health issues for residents.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. Specifically, Resident 5's hydromorphone, hydrocodone-acetaminophen, and lorazepam were found repacked in smaller plastic bags with no labels and placed back in the plastic medication container from the pharmacy. This practice was observed by LVN 4, who stated that it was done for faster counting, although she was unsure if the DON or ADON were aware of this practice. Further interviews with LVN 2 and RN 1 confirmed that repacking narcotics in smaller plastic bags was a common but unapproved practice, which could lead to infection control issues and drug diversion. The DON was unaware of this practice and confirmed that only pharmacists are authorized to repack narcotics, as per the facility's policy and procedure on medication labeling and storage. Additionally, the facility failed to ensure proper labeling and storage of omeprazole in medication cart three. Two boxes of omeprazole were found without received dates or expiration dates. LVN 1 confirmed the absence of these dates and acknowledged that residents could potentially receive expired medication, which could be less effective or have undesired side effects. The DON confirmed the lack of expiration dates on the boxes and stated that all medications in the carts are required to have expiration dates to prevent the administration of expired medications. The facility's policy and procedure on medication packaging, dated 10/2007, requires all unit dose medications to contain a lot number, expiration date, and product name. The observed deficiencies in medication storage and labeling practices indicate a failure to adhere to these policies, potentially compromising resident safety and care quality.
Failure to Provide Correct Dietary Supplements and Textures
Penalty
Summary
The facility failed to provide a well-balanced diet to meet the nutritional needs of several residents. Specifically, three residents continued to receive a nutritional supplement that had been discontinued by their physician. During observations and interviews, it was found that the kitchen staff was not properly informed of the discontinued supplements due to a lack of communication from the nursing staff. This resulted in residents receiving supplements that were no longer part of their prescribed diet, as evidenced by tray tickets and order audit reports that did not reflect the updated dietary orders. Additionally, two residents were given a chopped diet without a physician's order. The tray tickets for these residents indicated a chopped meat diet, while their official dietary orders specified a regular texture diet. Interviews with the Director of Nursing (DON) and the Registered Dietitian (RD) confirmed that the residents' diets should have been regular texture as per the physician's orders. The discrepancy between the tray tickets and the official orders highlighted a failure in the communication process between the nursing staff and the kitchen. The facility's policy and procedure documents state that all diet orders and changes must be communicated to the kitchen staff using a Diet Communication Form. However, this protocol was not followed, leading to the dietary errors. The lack of proper communication and adherence to established procedures resulted in residents receiving incorrect dietary supplements and textures, potentially impacting their nutritional needs and overall health.
Failure to Follow Prescribed Small Portion Diet
Penalty
Summary
The facility failed to ensure that the small portion diet for two residents, Resident 13 and Resident 21, was followed according to their alternate menu for lunch on March 25, 2024. During an observation in the kitchen, Cook 1 was seen using a #16 scoop (1/4 cup) of Spanish rice instead of the prescribed #12 scoop (1/3 cup) for the small portion diet. This discrepancy was confirmed during a review of the lunch tray tickets and the Daily Spreadsheet, which indicated the correct scoop size should have been #12. Cook 1 and the Dietary Service Supervisor (DSS) acknowledged the error when questioned by the surveyor team. Further interviews and record reviews revealed that both residents were on a small portion diet as per their Order Summaries. The Registered Dietitian (RD) confirmed that the kitchen staff did not follow the Daily Spreadsheet, which could potentially lead to weight loss for the residents if the correct portion sizes are not provided. The facility's Policy and Procedure on Food Service, dated 2018, also emphasized the importance of portion control to meet nutritional specifications and ensure resident satisfaction. The failure to adhere to the prescribed portion sizes had the potential to compromise the residents' caloric intake and medical status.
Failure to Ensure Proper Beard Restraint During Food Preparation
Penalty
Summary
The facility failed to ensure food was prepared in accordance with professional standards for food service safety when one of the kitchen staff, Cook 2, did not wear a beard restraint while preparing food. During an observation, Cook 2 was seen slicing and measuring roast beef with a surgical mask that only covered his mouth and nose, leaving his facial hair exposed. Later, Cook 2 was observed putting roast beef into a food processor without a beard restraint, which could potentially lead to hair falling into the food and causing contamination. Interviews with the Registered Dietitian (RD) and the Dietary Service Supervisor (DSS) confirmed that kitchen staff were expected to wear a snood or beard restraint during food preparation. The facility's policy and procedure, dated 2018, also indicated that all hair, including beards and mustaches, should be covered during meal preparation and service. Despite these guidelines, Cook 2 was not in compliance, leading to the observed deficiency.
Incomplete Medical Records and POLST Forms
Penalty
Summary
The facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards. One resident's medical record did not reflect the timely change of the humidifier bottle and the accurate amount of oxygen administered. This discrepancy was observed during an interview and record review, where it was found that the humidifier bottle was not changed as required every three days, leading to potential risks for the resident, such as dry, cracked, and bleeding mucosal membranes. The Director of Nurses confirmed that the documentation was inaccurate and that the humidifier bottle had not been changed as indicated in the medical administration record. Additionally, the facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) forms for four residents were complete. The POLST forms lacked essential information such as the physician's phone number and license number, which are crucial for honoring the residents' end-of-life wishes. During interviews and record reviews, it was revealed that the incomplete POLST forms could delay treatment and potentially violate the residents' or their families' wishes regarding life-sustaining measures. The facility's policy and procedure on charting and documentation emphasized the need for accurate and complete documentation. However, the observed deficiencies in both the humidifier bottle change records and the POLST forms indicate a failure to adhere to these standards. The incomplete documentation and inaccurate records pose significant risks to the residents' health and well-being, as well as their ability to have their treatment preferences respected in emergency situations.
Failure to Implement Safe Infection Control Measures
Penalty
Summary
The facility failed to implement safe infection control measures for two residents, Resident 2 and Resident 4, as observed by surveyors. Resident 4's urinary catheter tubing was found lying on the floor during an observation with the Director of Nursing (DON), who confirmed that the tubing should not be on the floor due to the risk of infection. Certified Nursing Assistant (CNA) 8 and Licensed Vocational Nurse (LVN) 6 also confirmed that catheter tubing should not be on the floor and should be covered to prevent contamination. Resident 4 had a history of obstructive and reflux uropathy, retention of urine, type II diabetes mellitus, and congestive heart failure, and was moderately cognitively impaired with a BIMS score of 12. Similarly, Resident 2's urinary catheter drainage bag was observed lying on the floor during the initial tour of the facility. LVN 8 and the Infection Preventionist (IP) verified that the catheter bag should not be on the floor, as it posed a risk of infection. Resident 2 had severe cognitive impairment with a BIMS score of 4 and was diagnosed with dementia, type 2 diabetes mellitus, anemia, neuromuscular dysfunction, hypertensive heart disease with heart failure, dysphagia, and benign prostatic hyperplasia without lower urinary tract symptoms. The facility's policy and procedure on urinary catheter care, dated August 2022, indicated that catheter tubing and drainage bags should be kept off the floor to prevent urinary tract infections. Additionally, the facility's infection control policy, dated October 2018, aimed to prevent, detect, investigate, and control infections within the facility. The failure to adhere to these policies was confirmed by multiple staff members, including the DON, CNA 8, LVN 6, LVN 8, the IP, and the Director of Staff Services (DSD).
Failure to Ensure Mandatory Staff Training
Penalty
Summary
The facility failed to ensure that Licensed Nurses (LNs), Certified Nursing Assistants (CNAs), and ancillary support staff received and demonstrated competency in preventing and recognizing resident abuse and in caring for residents with dementia. Specifically, 36 of 67 CNAs did not complete the 2023 annual mandatory in-service training for Dementia Module 1, and 47 of 67 CNAs did not complete Dementia Module 4. Additionally, 22 of 120 facility staff did not complete the mandatory in-service training for Fall Prevention, and 50 of 120 facility staff did not complete the mandatory in-service training for Abuse Prevention. These training modules are essential for ensuring that staff have the necessary skills and knowledge to provide safe and competent care to residents, particularly those with dementia or at risk of abuse and falls. During interviews and record reviews, the Director of Staff Development (DSD) confirmed that the mandatory training sessions were not attended by a significant portion of the staff. The DSD acknowledged that the Dementia modules, Fall Prevention, and Abuse Prevention trainings are required annually for all relevant staff members. The Director of Nursing (DON) also confirmed that these trainings are mandatory and should be completed annually to ensure proper care for the residents. The facility's Resident matrix indicated that 27 of 87 residents were diagnosed with Alzheimer's disease or dementia, highlighting the critical need for staff to be adequately trained in dementia care. The facility's policies and procedures emphasize the importance of in-service training for staff to understand resident rights, recognize signs of abuse, and manage aggressive or catastrophic resident behavior. The failure to ensure that all staff completed the required training sessions potentially placed residents at risk for inadequate care. The professional reference documents reviewed also support the necessity of regular training for nurse aides on dementia care and abuse prevention, as mandated by the Affordable Care Act and CMS guidelines.
Failure to Maintain Resident Dignity by Not Using Dignity Bags for Catheter Bags
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect when two residents' urinary catheter bags were not placed in dignity bags, making them visible from the hall outside the residents' rooms. Resident 2, who was admitted with diagnoses including Dementia, Type 2 Diabetes Mellitus, Anemia, Neuromuscular Dysfunction, Hypertensive Heart Disease with Heart Failure, Dysphagia, and Benign Prostatic Hyperplasia, had a BIMS score of 4, indicating severe cognitive impairment. Resident 26, admitted with diagnoses including Multiple Sclerosis, Anemia, Major Depressive Disorder, Muscle Weakness, Neuromuscular Dysfunction of Bladder, and Urinary Tract Infection, had a BIMS score of 9, indicating moderate cognitive impairment. During the initial tour, Resident 2's catheter bag was observed on the floor next to the bed, and Resident 26's catheter bag was attached to the wheelchair, both without dignity bags and visible from the hall. Interviews with staff, including an LVN, the Infection Preventionist, the Director of Staff Development, and the Director of Nursing, confirmed that the catheter bags were not in dignity bags, which was against the facility's policy. The facility's policy and procedure on dignity, dated February 2021, indicated that each resident should be cared for in a manner that promotes their sense of well-being and self-esteem, including keeping urinary catheter bags covered. The failure to follow this policy resulted in a violation of the residents' rights to dignity and respect.
Inaccurate MDS Assessment for Resident with Hemiplegia
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of Resident 65. Resident 65, who was admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, and atherosclerotic heart disease, was observed with limited mobility in her left arm due to a previous stroke. Despite this, the MDS assessment inaccurately coded Resident 65 as having no impairment in the upper extremity. Interviews with the resident, a Certified Nurse Assistant (CNA), and a Licensed Vocational Nurse (LVN) confirmed that Resident 65 required assistance with activities of daily living (ADL) due to the weakness in her left arm. The Minimum Data Set Registered Nurse (MDSRN) admitted to making an error in the assessment, acknowledging that Resident 65's left upper extremity did not have the same range of motion as her right upper extremity. The Director of Nursing (DON) also confirmed that Resident 65 should have been coded as having weakness in the upper extremity. The facility follows the Long Term Care Facility Resident Assessment Instrument (RAI) guidelines, which were not adhered to in this case, leading to the inaccurate assessment of Resident 65's functional limitations.
Failure to Complete PASRR Assessment for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was completed for a resident diagnosed with major depressive disorder, dementia, and psychotic disorder. The resident, who had been in the facility for more than eight years, was started on psychotropic medications on 12/2/19. However, the facility did not complete a new PASRR assessment to reflect the resident's diagnosis and use of psychotropic medications. The admission coordinator acknowledged the absence of a PASRR assessment after 11/8/19 and admitted that there should have been one completed. The facility did not have a policy on PASRR and relied on current regulatory guidelines instead. During an interview, the Director of Nursing confirmed that a new PASRR assessment should have been completed when the resident was started on psychotropic medications. The failure to complete the necessary PASRR assessment had the potential to prevent the resident from receiving the appropriate psychiatric level of treatment and evaluation. The deficiency was identified during a survey that included observation, interview, and record review.
Failure to Validate Competency of Infection Preventionist
Penalty
Summary
The facility failed to provide sufficient staff with the appropriate competencies and skill sets to ensure residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being. Specifically, the Infection Preventionist (IP) did not receive a competency skills check after being hired. The Director of Nursing (DON) and the Director of Staff Development (DSD) confirmed that the IP, who was responsible for the facility's infection prevention and control program, did not have her nurse competency validated. This oversight means the facility lacks proof that the IP can provide appropriate nursing care to residents, potentially placing them at risk of infection spread. The IP was hired and started her orientation but did not recall having her nurse competency checked by the DON or DSD. The facility's policy and procedure for newly hired employees require an in-depth orientation, including a review of infection control practices, but this was not completed for the IP. The facility's job description for the IP emphasizes the importance of maintaining current knowledge of regulations and performing duties related to infection prevention, yet the necessary competency validation was not conducted, leading to the identified deficiency.
Failure to Provide Metoprolol Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident 25 when their metoprolol medication, used to treat high blood pressure, was not available for administration on 3/27/24. During a medication pass observation, RN 1 noted that Resident 25's blood pressure was 150/85 and pulse was 85, but the metoprolol was not available. RN 1 stated that she would call the physician to notify them of the unavailability of the medication. The facility's policy requires that the attending physician be notified and the pharmacy be contacted when a medication is not available, but it was unclear if these steps were followed prior to RN 1's shift. Interviews with LVN 2 and the Director of Nursing (DON) revealed that licensed nurses are responsible for ensuring medications are available for administration. LVN 2 confirmed that the facility's practice is to call the MD and follow up with the pharmacy when a medication is not available. The DON stated that the nurse who administered the last dose should have followed up with the pharmacy. The facility's policies on medication shortages and non-controlled medication orders emphasize the importance of making every effort to ensure medications are available and notifying the prescriber if there is a delay in delivery or unavailability of the medication.
Inadequate Lighting in Medication Room
Penalty
Summary
The facility failed to provide a safe, functional, and comfortable environment in one of its medication rooms (Station 5), where only one of four fluorescent lights was working. This deficiency was observed during a survey on 3/26/24, at 3:50 p.m. with an LVN who noted the room was dark, making it difficult to read medication labels and increasing the risk of tripping and falling. The LVN was unaware if the issue had been reported to the maintenance department. An RN confirmed that the lights had been broken for at least two months and that no work order had been submitted to fix them. The RN also acknowledged the difficulty in reading medication labels and the potential for tripping due to the inadequate lighting. The Maintenance Facility Director (MFD) was unaware of the lighting issue until it was brought to his attention during the survey. He confirmed that the lighting situation was unsafe and that all lights should be functional. The facility's administrator stated that the lights were fixed on 3/26/24 but did not consider the lack of lighting an immediate health and safety hazard. The administrator mentioned that nurses could use alternative lighting methods, such as cell phone lights or flashlights, to read medication labels. The facility's policy and procedure on maintaining a homelike environment emphasized the importance of adequate lighting to promote safety and comfort, which was not adhered to in this case.
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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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