California Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 909 S Lake Street, Los Angeles, California 90006
- CMS Provider Number
- 055461
- Inspections on file
- 68
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 52 (2 serious)
Citation history
Health deficiencies cited at California Post Acute during CMS and state inspections, most recent first.
Two residents with DM, impaired cognition, and recent unplanned weight loss did not receive fully implemented and clearly specified nutritional and weight-monitoring interventions as outlined in their care plans. For one resident with dysphagia and pneumonitis, the care plan called for meal intake to be monitored and recorded at each meal, but intake was only documented on scattered dates and times, and the care plan did not specify the frequency, time of day, or type of scale for weight checks. For another resident with protein-calorie malnutrition and reduced mobility, the care plan also lacked defined frequency, time, and scale for weight monitoring despite a documented seven-pound loss in one week. The DON confirmed that meal intake monitoring was inconsistent and that both care plans were missing specific details required for effective weight management.
A resident with DM, protein calorie malnutrition, reduced mobility, moderately impaired cognition, wounds, and an indwelling catheter required extensive assistance with ADLs. The MDS documented the indwelling catheter, and the resident was observed in bed with the catheter in place, but the care plan only reflected Enhanced Barrier Precautions (EBP) for a wound and did not include the catheter. During interview and record review, the DON confirmed the resident should be on EBP due to both wounds and the indwelling catheter and that no physician order for EBP had been obtained, despite facility policies requiring timely care plan revision and indicating EBP for residents with wounds and/or indwelling medical devices.
A resident with morbid obesity, muscle weakness, chronic pain syndrome, and impaired lower-extremity ROM, who was cognitively intact and wheelchair-bound, received a special manual wheelchair paid for by health insurance and delivered to the facility for her personal use. The wheelchair was not added to the resident’s personal property inventory as required by facility policy, and when the resident was transferred to a hospital and later admitted to another facility, the wheelchair was not returned. The ADM reported not knowing what happened to the wheelchair and confirmed it was not listed on the belongings inventory, while the DOR and the wheelchair company confirmed that the wheelchair was resident-owned and that the facility was responsible for its safekeeping, resulting in the resident being without her wheelchair for mobility.
A resident with multiple medical and behavioral diagnoses left the facility unsupervised and was missing for several hours before returning. Staff notified the police and searched for the resident, but did not report the elopement to the State Survey Agency or investigate how the resident was able to leave, contrary to facility policy.
Two exit doors, including the main entrance and a door near the kitchen, were found to have non-functioning locks. Multiple staff members, including an LVN, housekeeping, the receptionist, the maintenance supervisor, and the DON, were unable to secure these doors after visiting hours as required by facility policy. Policy review confirmed the expectation that these doors be locked at night for safety.
A resident with schizophrenia and other medical conditions was not permitted to return to the facility after a psychiatric hospitalization, despite being ready for discharge and the facility's policy allowing return after hospitalization. The facility refused re-admission due to the resident's prior aggressive behavior and AMA departure, without required physician documentation supporting the refusal.
A resident with multiple medical conditions did not have a physician-ordered blood draw completed as scheduled. The lab service log indicated a refusal, but the resident denied refusing, and there was no documentation in the nursing notes to support a refusal. The LVN signed the log but did not document the event, and the DON confirmed that such refusals should be documented and the physician notified.
A resident with schizophrenia and end stage renal disease experienced continuous side effects from Quetiapine, as documented in the MAR over multiple days. Despite facility policy and physician orders requiring monitoring and notification for adverse reactions, staff did not notify the physician or initiate a Change of Condition, as confirmed by interviews with the RN Supervisor and DON.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility did not ensure that dialysis care was provided according to the resident's requirements.
The facility did not ensure proper care for pressure ulcers and failed to prevent new ulcers from developing. Staff did not consistently follow protocols for assessment, monitoring, and treatment, leading to inadequate interventions for a resident with existing ulcers and insufficient preventive measures for those at risk.
The QAPI and QAA committees did not identify or discuss issues related to CPR and dialysis, as confirmed by the absence of these topics in meeting minutes and statements from the IDON. This failure meant that concerns affecting residents needing dialysis or CPR were not addressed by the facility's quality improvement processes.
Two residents received psychotropic medications without adherence to required protocols: one continued on an antipsychotic without a documented gradual dose reduction despite no recent symptoms, and another received anti-anxiety medication without informed consent from the responsible party, even though the resident was unable to make medical decisions. Facility policy requiring informed consent and regular medication review was not followed.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation of the resident's care needs.
The facility did not maintain complete employee files for several staff members, including an LVN, a treatment nurse, and the interim DON, as required documentation such as performance evaluations, skills competency checklists, and BLS certifications were missing. Interviews and record reviews confirmed these omissions, despite facility policies mandating such records to ensure staff competency and CPR readiness.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
Surveyors found that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the acceptable threshold.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
During a meal service, pureed foods including meat, corn, and potato were prepared with a thin, loose consistency that did not meet IDDSI Level 4 standards. The Dietary Supervisor and a cook confirmed the foods did not hold their shape and were more liquid than required, due to excess liquid being added during preparation. Facility recipes and IDDSI guidelines specify that pureed foods must be smooth, hold their shape, and pass specific consistency tests, which was not achieved in this instance.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Surveyors observed that trash bins, including one large bin and two recyclable bins, were left uncovered and overfilled with boxes, with a cat present in the area. Both the dietary and maintenance supervisors acknowledged that bins should be covered and boxes broken down to prevent pest attraction, but these practices were not followed, resulting in unsanitary conditions.
A resident with heart failure and muscle weakness experienced a lack of privacy because of broken window blinds, which allowed visibility into her room from the main street. Staff and the DON acknowledged that the issue affected resident privacy and comfort, and the facility's policy on dignity was not upheld.
Staff did not promptly inform a resident, the resident's doctor, and a family member about events such as injury, decline, or room changes that affected the resident, as required by regulations.
A resident with multiple chronic conditions was not provided with a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) when Medicare Part A skilled services ended, despite facility policy requiring such notification. Staff interviews revealed a lack of understanding of the SNFABN process, and the resident was not informed of their potential financial liability or appeal rights.
A resident was discharged home in stable condition with her family and medications, but the facility did not complete or transmit the required MDS discharge assessment to CMS. Review of records and staff interviews confirmed that the discharge MDS was not created or sent, as required by facility policy and federal regulations.
A resident with incontinence, limited mobility, and multiple comorbidities developed Moisture-Associated Skin Damage (MASD) in the perineal area due to insufficient perineal care and inadequate monitoring for incontinence. Despite a care plan outlining necessary interventions, staff provided perineal care only twice per shift, leading to skin breakdown, pain, and visible skin injury.
A resident with multiple medical conditions and impaired hand mobility did not receive prescribed resting hand splints due to their unavailability, as observed by staff and confirmed through interviews. This omission led to worsening contractures and pain during passive range of motion exercises, despite clear therapy recommendations and facility policy requiring such interventions.
A resident with significant mobility impairments and on anticoagulant therapy was not frequently visually monitored as required by the care plan, despite being at high risk for falls. The resident was found with curtains drawn around the bed, making monitoring difficult, and staff confirmed that frequent checks were not performed. The resident experienced a fall but did not sustain injury. The facility's fall risk assessment was inaccurate, and the policy requiring adequate supervision was not followed.
A resident with a gastrostomy tube was found with an unlabeled and undated syringe and tube feeding formula at the bedside. An LVN confirmed the items should have been labeled and dated, and the interim DON acknowledged that this failure could result in expired formula being administered. Facility policy requires all enteral feeding containers to be properly labeled and dated to ensure safe administration.
A resident with heart failure and muscle weakness, who required assistance with food setup, was served a meal containing items specifically listed as dislikes on their meal ticket. The resident also reported not consistently receiving preferred meal options, and the dietary supervisor confirmed that such preferences are accessible to kitchen staff but were not followed.
The facility did not ensure proper infection control measures for two residents: one did not have a required physician order for enhanced barrier precautions (EBP) despite having wounds, and another had conflicting signage for contact precautions and EBP outside their isolation room, potentially causing staff confusion about PPE use. These lapses were identified through observation, interview, and record review.
Rooms designated for multiple residents were found to be less than 80 square feet per resident, and single resident rooms were less than 100 square feet, as required by regulations.
Two laundry carts containing clean linen and towels were observed stored in the facility's parking lot, covered with plastic, due to a lack of indoor space. The Maintenance Supervisor confirmed the carts held clean linen, and the interim DON stated this practice was unhygienic and an infection control issue. Facility policy requires clean linen to be stored and transported in a safe and aseptic manner, with carts covered and kept in designated indoor areas.
A resident with impaired cognition and a known elopement risk left the facility unsupervised while an LVN was assisting another individual. Although the facility notified police, family, and internal leadership, the DON and administrator did not report the elopement to the SSA as required by policy, resulting in a delay in investigation and assurance of the resident's safety.
A resident with cognitive impairment and a documented risk for elopement was left unsupervised when the assigned staff member assisted another individual, resulting in the resident leaving the facility and being found several miles away. Despite care plans and facility policy requiring one-to-one supervision, this was not provided at the time of the incident.
A resident with multiple diagnoses, including Parkinson's disease and heart failure, was identified as underweight and in need of additional calories. Despite being assessed as malnourished and receiving high protein supplements, no care plan was developed or implemented to address or monitor the resident's nutritional and hydration needs, contrary to facility policy.
A resident with multiple health conditions and an indwelling catheter did not have their fluid intake and urine output consistently monitored as ordered by the physician, and was not provided with a fortified diet as recommended by the RD. The RD did not follow up on the resident's nutritional needs after the initial assessment, and documentation of urine output was incomplete, leading to inadequate evaluation of the resident's hydration and nutritional status.
A resident who was dependent on staff for toileting and other daily activities did not receive timely assistance during the night shift due to inadequate CNA staffing. Only two CNAs were available for 48 residents after two scheduled CNAs called in sick and were not replaced, resulting in the resident waiting for hours for help and experiencing distress.
A facility failed to follow physician orders for a resident with dysphagia, gastrostomy, and dementia, resulting in unmonitored nutritional and fluid needs. The resident experienced significant weight loss, and the registered dietitian did not conduct necessary assessments or meetings. Additionally, the facility did not document intake and output monitoring as ordered, despite the resident receiving gastrostomy tube feeding. The facility's policies required comprehensive nutrition assessments and monitoring, which were not adhered to.
A facility failed to follow physician orders for a resident receiving enteral nutrition through a gastrostomy tube, including maintaining head elevation and checking tube placement. The resident, with conditions such as dysphagia and dementia, was at high risk for aspiration. The lack of adherence to these protocols was confirmed by the DON and a nurse practitioner, who noted the potential for aspiration pneumonia due to improper positioning.
A facility failed to document a care meeting for a resident with dysphagia, a gastrostomy, and dementia, resulting in an incomplete medical record. Despite the meeting involving the resident's responsible party and facility staff, it was not recorded due to being considered informal. The DON acknowledged the need for documentation as per facility policy.
A resident with schizoaffective disorder and cognitive impairment exhibited aggressive behavior, which was not properly assessed or addressed by the facility's interdisciplinary team. This led to the resident sexually abusing a cognitively impaired roommate. The facility failed to follow its policies on behavior assessment and abuse prevention, resulting in a deficiency in protecting residents from abuse.
A resident reported a fall and subsequent back pain, but the LTC facility failed to assess the resident immediately or notify the physician promptly. The resident contacted his own doctor, who ordered an MRI, but the facility delayed the MRI by 19 days due to authorization issues. The facility did not follow its policies on change in condition and assessing falls, leading to significant deficiencies in care.
A resident with visual impairment and a history of falls experienced another fall due to the facility's failure to follow physician's orders for visual hourly safety checks and to update the At Risk for Falls Care Plan. The resident fell from the bed, resulting in a laceration and subsequent admission to the ICU for an acute stroke. The facility's outdated care plans and incorrect documentation contributed to inadequate supervision and failure to implement necessary interventions.
A resident was administered quetiapine fumarate (Seroquel) without informed consent. Despite being cognitively intact, the resident was not informed about the medication's risks and benefits and did not sign a consent form. The DON confirmed the oversight, which violated the facility's policy requiring informed consent documentation before administering psychotherapeutic drugs.
A facility failed to provide proper indication and monitoring for a resident started on Seroquel. The physician's order lacked the indication and targeted behavior, and the informed consent was incomplete. The resident was not monitored for adverse reactions, contrary to facility policy. Interviews with staff confirmed these deficiencies.
A resident with a high fall risk and dependency on staff for toilet transfers fell and sustained a hip fracture due to inadequate supervision and assistance. The facility failed to follow the care plan requiring assistance every two hours, and care plans were not updated or revised as needed. Staff interviews revealed the resident was confused and did not consistently use call lights, and the facility did not document required rounds for toileting assistance.
A facility failed to update a resident's care plans quarterly, as required, for risks related to falls, incontinence, and ADLs. The resident, with a history of muscle weakness, cognitive deficits, and chronic kidney disease, was dependent on staff for mobility and toileting. Despite the facility's policy mandating quarterly updates, the care plans were not revised in June 2024, as confirmed by staff interviews.
A resident with severe cognitive impairment and incontinence was not properly monitored for bladder habits, leading to a fall and injury. The care plan required assistance every two hours, but staff conducted random checks instead. The resident attempted to go to the bathroom independently, resulting in a fall and a fracture. The facility failed to update the care plan to address the resident's high fall risk.
A resident with moderate cognitive impairments alleged being slapped by a CNA, an incident supported by another resident and a CNA who heard the slap. Despite reports to the RN and DON, the facility failed to investigate or report the incident to authorities. The facility's policy requires thorough investigation and reporting, but no documentation was provided to confirm this occurred.
A resident was injured during a transfer using a hoyer lift when a CNA failed to control the lift properly, causing it to lower quickly and hit the resident in the face. The facility did not investigate the incident or inspect the lift for malfunctions, contributing to the deficiency.
Failure to Implement and Specify Nutritional and Weight Monitoring in Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to implement and specify care plan interventions related to nutritional monitoring and weight management for two residents with unplanned weight loss. For one resident with diagnoses including DM, dysphagia, and pneumonitis, and with moderately impaired cognition and dependence on staff for most ADLs, the care plan initiated on 12/31/25 identified unplanned/unexpected weight loss related to poor oral intake and food refusal, with a goal of no further weight loss for three months. The care plan interventions required monitoring and recording food intake at each meal and weighing the resident at the same time using a specified scale, but the frequency, time of day, and scale type were not actually documented. Review of the meal intake records showed that this resident’s intake was only recorded on scattered dates and times rather than after each scheduled meal, and the DON acknowledged that monitoring of this resident’s meal intake was inconsistent despite established mealtimes. For the second resident, admitted with DM, protein-calorie malnutrition, reduced mobility, moderately impaired cognition, and dependence or substantial assistance for most ADLs, the care plan initiated on 12/10/25 documented an unplanned/unexpected seven-pound weight loss in one week related to disease process, with a goal of no further weight loss for three months. The nursing interventions included weighing the resident at the same time of day and recording the weight, but again the care plan did not specify the frequency of weighing, the time of day, or the scale to be used. During concurrent interview and record review, the DON confirmed that the care plans for both residents lacked these specific details and stated that the care plan should be specific and thorough. Facility policies on comprehensive care plans and weight management required development and implementation of person-centered care plans and review and updating of care plans as indicated, but the documented care plans for these two residents did not include the required specificity for weight monitoring.
Failure to Revise Care Plan and Obtain EBP Order for Resident With Indwelling Catheter
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to timely and accurately revise the comprehensive care plan and obtain appropriate orders related to infection control precautions for one resident. The resident was admitted with diagnoses including diabetes mellitus, protein calorie malnutrition, and reduced mobility, and had moderately impaired cognition per the MDS. The MDS also documented that the resident had an indwelling catheter and was dependent on staff for toileting hygiene, bathing, dressing, and required assistance with oral hygiene and eating. The facility’s care plan, initiated on 7/3/24, indicated the resident was on Enhanced Barrier Precautions (EBP) due to a wound but did not reflect that the resident also had an indwelling catheter, despite this being documented elsewhere in the record. During observation, the resident was seen lying in bed with an indwelling catheter hanging on the right side of the bed. In a concurrent interview and record review with the DON, it was confirmed that the resident should be on EBP because of both wounds and the indwelling catheter, and that there was no physician order in place to initiate EBP for this resident. The DON acknowledged that the care plan should be revised and that a physician order was needed to place the resident on EBP. Facility policies stated that care plans must be reviewed and revised at least quarterly or more often as the resident’s condition warrants, and that EBP are indicated for residents with wounds and/or indwelling medical devices even if they are not known to be infected or colonized with MDROs. The failure to revise the care plan to include the indwelling catheter and to obtain a physician order for EBP had the potential to spread infection to other residents, staff, and visitors.
Failure to Safeguard and Inventory Resident-Owned Wheelchair Resulting in Loss
Penalty
Summary
The facility failed to protect a resident’s personal property and maintain an accurate inventory of belongings, resulting in the loss of the resident’s wheelchair. The resident, who had diagnoses including morbid obesity, muscle weakness, and chronic pain syndrome, was cognitively intact and used a manual wheelchair for mobility, with impaired range of motion in both lower extremities. Social services documentation showed that the resident was evaluated by a wheelchair company for a special wheelchair and that the new wheelchair was delivered to the resident, with the facility’s social service designee signing the delivery ticket. The wheelchair was paid for by the resident’s health insurance and was owned by the resident. However, the wheelchair was never added to the resident’s clothing and possessions list, despite facility policy requiring that personal belongings be inventoried upon admission and as items are replenished. When the resident was transferred to a general acute hospital and later admitted to another facility, the resident’s wheelchair was not returned. During interviews, the director of rehabilitation confirmed that the resident was wheelchair-bound, that the wheelchair was specifically fitted for the resident, and that it belonged to the resident for her own use and to take upon discharge. The administrator stated he did not know what happened to the wheelchair, acknowledged there was no invoice available, and confirmed the wheelchair was not added to the resident’s belongings list. A customer service representative from the wheelchair company confirmed that the resident’s health insurance paid for the wheelchair, that it was delivered to the facility, that the resident owned it, and that the facility was responsible for replacing the lost wheelchair. These failures resulted in the resident’s wheelchair being lost and the resident not having a wheelchair for mobility.
Failure to Report and Investigate Resident Elopement
Penalty
Summary
The facility failed to implement its abuse policy for one of two sampled residents when it did not report an elopement incident to the State Survey Agency (SSA) and did not investigate how the resident was able to leave the premises unsupervised. The resident, who had diagnoses including low back pain, osteomyelitis of the left shoulder, and a history of mental and behavioral disorders, was cognitively intact and required varying levels of assistance with daily activities. On the date of the incident, staff discovered the resident missing at approximately 6:30 a.m. and were unable to locate him despite searching the facility and contacting local hospitals. Attempts to reach the resident by cell phone were unsuccessful, and the police were notified to assist in the search. The resident returned to the facility at 1 p.m. the same day, at which point the police were informed that the missing person case was resolved. Documentation in the nursing progress notes confirmed the timeline of the resident's absence and the actions taken by staff, including notification of the physician and police. Interviews with staff, including LVNs, the registered nurse supervisor, the DON, and the administrator, revealed that the incident was not reported to the SSA as required by facility policy. Additionally, there was no investigation into how the resident was able to elope from the facility. The facility's policies on wandering, elopement, and reporting of alleged violations require immediate reporting and investigation of such incidents, but these procedures were not followed in this case.
Failure to Maintain Functioning Locks on Exit Doors
Penalty
Summary
The facility failed to ensure that two of five exit doors, specifically the main entrance (Door 1) and the door near the kitchen (Door 2), were properly fitted with functioning locks. Multiple staff members, including an LVN, housekeeping personnel, the receptionist, the maintenance supervisor, and the DON, attempted to lock these doors using their keys but were unable to do so. Observations and interviews confirmed that both doors could not be locked, even after visiting hours, despite facility policy requiring these doors to be secured at night for safety reasons. A review of the facility's policies and procedures indicated that the maintenance director is responsible for maintaining a safe and operable environment, including ensuring that doors are locked as required. The receptionist and maintenance supervisor both stated that the doors should be locked after visiting hours, especially given the facility's location. The DON also confirmed that the doors do not latch and should be locked for safety. The lack of functioning locks on these doors was directly observed and verified through staff interviews and policy review.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after hospitalization, violating the resident's right to return and remain at the facility. The resident, who had diagnoses including schizophrenia, osteoarthritis of the knees, and generalized muscle weakness, was admitted and noted to be alert and oriented. On the morning of the incident, the resident became verbally and physically aggressive, leading staff to contact the police. The resident expressed a desire to leave against medical advice (AMA), was informed of the risks and benefits, but refused to sign the AMA form. The police subsequently took the resident to a general acute care hospital (GACH) for psychiatric evaluation. When the hospital contacted the facility to coordinate the resident's discharge and return, the facility refused re-admission, citing the resident's prior aggression and AMA departure. Facility staff, including the admission coordinator and administrator, confirmed the refusal, stating the resident was not welcome back due to the incident. There was no physician documentation indicating the facility was an inappropriate placement for the resident, and the facility's own policy permitted residents to return following hospitalization or therapeutic leave. The policy also required specific physician documentation if a transfer or discharge was necessary for safety reasons, which was not present in this case.
Failure to Obtain and Document Ordered Blood Draw
Penalty
Summary
The facility failed to ensure that a blood sample was collected from a resident as ordered by the physician. The physician had ordered a complete blood count (CBC), basic metabolic panel (BMP), c-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to be obtained on a specific date. The laboratory service log indicated that the resident refused the blood draw, and this was signed by an LVN. However, during an interview, the resident stated that he was waiting for the blood sample to be collected and was told he had refused, which he denied. There was no documentation in the nursing progress notes to confirm that the resident refused the blood draw, and the LVN stated she did not document a refusal. The registered nurse supervisor confirmed the lack of documentation and stated that such events should be recorded to clarify what occurred. The resident involved had been admitted with diagnoses including osteomyelitis of the cervical region, right ankle and foot, and diabetes mellitus, and required substantial assistance with daily activities. The facility's policies required that laboratory services ordered by a physician be completed in a timely manner and that any deviations, such as a resident refusal, be documented in the nursing notes. The director of nursing also confirmed that refusals should be documented and the physician notified. The failure to document the refusal and to obtain the blood sample as ordered constituted the deficiency.
Failure to Notify Physician and Initiate Change of Condition for Ongoing Antipsychotic Side Effects
Penalty
Summary
The facility failed to meet professional standards of quality for one resident by not notifying the physician or initiating a Change of Condition (COC) when the resident experienced continuous side effects from Quetiapine, an antipsychotic medication. The resident, who had diagnoses including schizophrenia and end stage renal disease requiring dialysis, was documented as experiencing side effects such as sedation, drowsiness, and other symptoms on multiple consecutive days, as recorded in the Medication Administration Record (MAR). Despite these ongoing side effects, there was no evidence that the physician was notified or that a COC was initiated, as required by facility policy and physician orders. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that the physician should have been notified and a COC initiated due to the persistent side effects. The facility's policies required monitoring, documentation, and reporting of adverse reactions to antipsychotic medications, as well as physician notification for significant changes in a resident's condition. However, these procedures were not followed, as indicated by the lack of documentation of physician notification or COC initiation, despite clear evidence of ongoing adverse effects.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that staff did not consistently follow established protocols for pressure ulcer prevention and care, resulting in inadequate interventions for residents with existing ulcers and insufficient preventive actions for those at risk.
QAPI Committee Failed to Address CPR and Dialysis Concerns
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to identify and address concerns related to cardio-pulmonary resuscitation (CPR) and dialysis services. During an interview and record review with the Interim Director of Nursing (IDON), it was confirmed that CPR and dialysis were not discussed or included in the QAPI meeting minutes. The IDON acknowledged that if these topics were not listed in the meeting minutes, they were not addressed during the QAPI meeting. A review of the facility's QAPI policy indicated that the committee is responsible for identifying and addressing specific care and quality issues, implementing action plans, and using data to monitor performance. Despite this, the QAPI committee did not include CPR and dialysis in their discussions or evaluations, as evidenced by the absence of these topics in the meeting minutes. This omission had the potential to impact residents who receive dialysis or require CPR, as concerns in these areas were not identified or addressed by the committee.
Failure to Ensure Gradual Dose Reduction and Proper Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary psychotropic medications and that proper procedures were followed regarding medication management. For one resident with a history of schizophrenia, cognitive communication deficit, and depression, the facility did not perform a required gradual dose reduction (GDR) for risperidone, despite a medication regimen review indicating that a GDR was due. Documentation showed that the resident had not exhibited symptoms such as hallucinations or behavioral disturbances for several months, yet the antipsychotic medication was continued at the same dosage without documented clinical justification or evidence of a GDR attempt. Additionally, the facility failed to obtain proper informed consent for the administration of alprazolam to another resident diagnosed with dementia, schizophrenia, and anxiety. Although the resident was taking anti-anxiety medication, the informed consent form was signed by the resident, who was documented as unable to make medical decisions, rather than by the responsible party (RP) designated to make such decisions. Both nursing staff and the interim director of nursing confirmed that the RP should have provided consent, and acknowledged that the lack of RP signature meant the resident and their representative may not have been fully informed about the medication being administered. Facility policy required that residents or their representatives be informed of the risks, benefits, and alternatives to psychotropic medications, and that documentation of this informed consent be maintained. In both cases, the facility did not adhere to its own policies and procedures regarding psychotropic medication management and informed consent, resulting in deficiencies related to medication safety and resident rights.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey and was based on a review of the resident's records, which did not contain a comprehensive care plan as required.
Incomplete Staff Competency and Certification Documentation
Penalty
Summary
The facility failed to ensure that the employee files for three of five sampled staff members, including a Licensed Vocational Nurse, a Treatment Nurse, and the Interim Director of Nursing, contained required documentation such as performance evaluations, skills competency checklists, and Basic Life Support (BLS) certifications. During interviews and record reviews with the Director of Staff Development, it was found that the Licensed Vocational Nurse's file was missing a BLS certification, skills competency checklist, and a current performance evaluation. The Interim Director of Nursing's file lacked a skills competency checklist, and the Treatment Nurse's file was missing both a skills competency checklist and a current performance evaluation. The Director of Staff Development and the Interim Director of Nursing confirmed that these documents were not present in the respective employee files and acknowledged the importance of having them to ensure staff proficiency and readiness to provide care, including resuscitative efforts. Facility policies reviewed indicated that employee job performance should be evaluated and that staff should be properly trained in CPR, but these requirements were not met for the sampled employees.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices and the resulting error rate.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals within the facility.
Failure to Follow IDDSI Level 4 Pureed Diet Standards
Penalty
Summary
The facility failed to ensure that standardized recipes for pureed diets were followed during lunch service, resulting in pureed foods that did not meet the required International Dysphagia Diet Initiative (IDDSI) Level 4 consistency. Observations during the tray line service revealed that pureed meat, corn, and potato had a thin and loose consistency, spreading out flat on the plate and failing to hold their shape. When tested, the pureed foods dripped through the fork prongs and were described as being on the liquid side. Both the Dietary Supervisor and the cook confirmed that the pureed foods were not at the correct consistency, with the cook admitting to using more liquid than the recipe specified in an attempt to make the food smoother. A review of the facility's recipes for pureed meats and vegetables indicated that foods should be pureed to a paste consistency before adding any liquid, and the finished product should be smooth, free of lumps, hold its shape, and not separate into liquid and solid. The recipes also required that the pureed foods pass IDDSI Level 4 testing methods, including the fork drip, fork pressure, and spoon tilt tests. The IDDSI guidelines further specify that Level 4 pureed foods should fall off a spoon in a single spoonful, hold their shape on the plate, and not have liquid separation. These requirements were not met during the observed meal service.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Unsanitary Trash Storage and Uncovered Bins
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster areas in a sanitary manner. During an observation, one large trash bin was found uncovered and two recyclable trash bins were overfilled with boxes and left uncovered. A cat was observed around the trash area in the parking lot. The dietary supervisor confirmed that trash bins needed to be covered to prevent animals from feeding and to avoid attracting flies. The maintenance supervisor also stated that trash was picked up twice a week, boxes should be broken down to allow more space, and lids should be closed to prevent animals from accessing the trash and to deter pests. A review of the facility's policy and procedures indicated that garbage and refuse containers are to be maintained in good condition and waste is to be properly contained in dumpsters or compactors with lids covered. Additionally, the FDA Food Code requires that receptacles and waste handling units for refuse, recyclables, and returnables kept outside must be covered with tight-fitting lids or doors, and stored so that they are inaccessible to insects and rodents. The facility did not adhere to these requirements, resulting in the observed deficiency.
Resident Privacy Compromised Due to Broken Window Blinds
Penalty
Summary
A deficiency was identified when a resident's right to privacy and dignity was not maintained due to broken window blinds in her room. Observations revealed that one set of blinds had 22 broken slats out of 39, and another set had 5 broken slats out of 33, making the room visible from the main street. The resident reported that someone had measured the windows for new blinds weeks prior, but no further action had been taken, and she continued to lack privacy. The resident expressed concerns about her privacy, especially at night when staff turned on the lights during care, making her visible from outside. Staff interviews confirmed the issue, with a CNA acknowledging that the broken blinds allowed people outside to see into the room and that this could be a privacy issue affecting residents emotionally. The Interim Director of Nursing also confirmed that most rooms faced outside and that the lack of privacy could impact residents' comfort. The facility's policy on dignity emphasized care that promotes and enhances quality of life and dignity, which was not upheld in this instance.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Provide Required SNFABN Notification to Resident
Penalty
Summary
The facility failed to provide a required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) to a resident when Medicare Part A skilled services were ending, as indicated by a review of the resident's records and staff interviews. The resident, who was cognitively intact and had multiple diagnoses including muscle weakness, dysphagia, COPD, type 2 diabetes mellitus, and chronic kidney disease, was not given the SNFABN prior to the termination of Medicare coverage, despite remaining in the facility. The SNF Beneficiary Notification Review form confirmed that the last covered day for Medicare Part A services had passed, and the resident had not exhausted benefit days, yet no SNFABN was issued. Interviews with the Admissions staff and Interim Director of Nursing revealed a lack of familiarity with the SNFABN process and uncertainty about why the notice was not provided. The facility's policy and procedure required that residents be informed of their potential liability for non-covered services and be given the SNFABN at the initiation, reduction, or termination of services. However, the responsible staff did not follow this policy, resulting in the resident not being informed of the end of Medicare coverage or their appeal rights.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) discharge assessment was created and transmitted to the Centers for Medicare and Medicaid Services (CMS) for a resident who was discharged home. The resident had been admitted with diagnoses including urinary tract infection, dysphagia, muscle weakness, and transient cerebral ischemic attack, and was noted to be cognitively intact. Documentation showed that the resident was discharged in stable condition with her family and medications, but review of records and interviews with the MDS Coordinator confirmed that a discharge MDS assessment was not completed or transmitted as required. Facility policy states that MDS data must be encoded and transmitted to CMS within specified timeframes following a resident's discharge. The MDS Coordinator acknowledged that the discharge MDS should have been created on the day of discharge and transmitted within the required period, but this was not done. The last MDS assessment in the system for the resident was a quarterly assessment, and no discharge MDS was present. The Interim Director of Nursing also confirmed that the discharge MDS assessment was not completed or transmitted, which could potentially delay discharge care for the resident.
Failure to Maintain Perineal Skin Integrity in Dependent Resident
Penalty
Summary
A resident with a history of left above-the-knee amputation, stage 2 pressure ulcer, type 2 diabetes mellitus, and schizophrenia was admitted to the facility and assessed as always incontinent of bladder and bowel, requiring substantial to maximal assistance for activities of daily living, including toileting and personal hygiene. The resident was identified as being at risk for skin injuries, with a care plan in place to keep the skin clean and dry, conduct frequent visual checks, and reposition the resident regularly. Despite these interventions, staff interviews and observations revealed that the resident received perineal care only twice during an 8-hour shift and developed redness, weeping, and excoriation in the perineal area. The resident reported pain during perineal care, and a treatment nurse confirmed the presence of Moisture-Associated Skin Damage (MASD) and dermatitis, with a denuded line and watery exudate below the coccyx, attributed to prolonged exposure to urine and feces due to incontinence. Review of facility policy indicated that exposure to urine and feces increases the risk of skin breakdown, especially in residents with impaired mobility and other comorbidities. The policy required evaluation of resident-specific risk factors and implementation of interventions to prevent skin damage. However, the findings showed that the resident's skin was not maintained in a clean and intact condition, and monitoring for incontinence was insufficient, as the resident should have been checked every two hours. This failure resulted in the development of MASD and discomfort for the resident.
Failure to Apply Prescribed Hand Splints Resulting in Worsening Contractures
Penalty
Summary
A resident with a history of right femur fracture, diabetes mellitus, and osteoarthritis was admitted to the facility and assessed as requiring supervision and maximal assistance for activities of daily living. The resident had physician orders and occupational therapy recommendations for the application of resting hand splints to both hands for two hours daily, five times a week, to address impairments and prevent contractures. However, during observations, the resident was seen without the prescribed hand splints, and both hands were noted to be in a contracted position. The Restorative Nurse Assistant (RNA) reported being unable to apply the splints because they were missing. Further review and interviews revealed that the resident experienced pain during passive range of motion exercises, and the occupational therapist determined that the right hand contracture had worsened, with a new contracture developing in the left hand. The facility's policy required the provision of specialized rehabilitative services as assessed in the comprehensive care plan, but the prescribed intervention of hand splint application was not carried out due to the unavailability of the splints.
Failure to Implement Fall Risk Care Plan and Provide Adequate Supervision
Penalty
Summary
The facility failed to implement the fall risk care plan for one resident by not providing frequent visual monitoring as required. The resident, who had a history of necrotizing fasciitis, generalized muscle weakness, lower leg osteomyelitis, and chronic ulcers on both feet, was admitted with significant mobility impairments and required supervision and assistance with activities of daily living. The care plan specifically called for frequent visual checks to prevent falls, but during observation, the resident was found with curtains drawn around the bed, making visual monitoring difficult, and was not wearing non-slip socks. The resident reported always having the curtains drawn, further impeding staff's ability to monitor her. A review of records revealed that the resident was taking multiple medications, including anticoagulants and antihypertensives, and was assessed as unable to self-transfer. Despite these risk factors, staff interviews confirmed that frequent visual monitoring was not being performed. The resident experienced a fall during the night and self-reported getting back up without injury. The facility's Fall Risk Assessment was found to be inaccurate, and the Interim Director of Nursing acknowledged the importance of following the care plan for frequent monitoring, emphasizing that it is the responsibility of all staff to ensure the resident's safety. The facility's policy required adequate supervision to prevent accidents, which was not followed in this case.
Failure to Label and Date Tube Feeding Supplies
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube received appropriate treatment and services to prevent complications related to tube feeding. Specifically, during an observation, an unlabeled and undated syringe and a container of tube feeding formula were found on the resident's bedside dresser. The nurse present confirmed that both the tube feeding container and syringe should have been labeled and dated, and subsequently disposed of the items. The resident in question had diagnoses including dysphagia and gastrostomy, with severely impaired cognition, and was receiving enteral feeding as ordered by a physician. Further review of facility policy indicated that all enteral feeding containers must be labeled with the resident's name, formula type, date, and time of preparation, and that open system formulas should be discarded within eight hours. The facility's interim DON confirmed that failure to label and date tube feeding containers could result in staff not knowing how long the formula had been out, potentially leading to expired formula being administered. The lack of labeling and dating was a direct violation of the facility's policy and placed the resident at risk for gastrointestinal complications.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's documented dietary preferences by providing food items that were specifically listed as dislikes on the resident's meal ticket. The resident, who had diagnoses including heart failure and muscle weakness and required assistance with food setup, received a lunch meal consisting of corn, mashed potatoes, and meat with gravy, despite mashed potatoes and gravy being listed as disliked foods. The resident also reported inconsistencies in receiving preferred meal options, such as receiving an omelet instead of scrambled eggs and incomplete toppings for chef's salads. The dietary supervisor confirmed that resident preferences are available to the kitchen through their diet system and acknowledged that receiving disliked foods could result in the resident being upset and not eating. The facility's policy requires that food provided accommodates resident allergies, intolerances, and preferences, but this was not followed in the case of this resident.
Failure to Implement and Communicate Proper Infection Control Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two specific deficiencies. For one resident with diagnoses including necrotizing fasciitis, osteomyelitis, and chronic foot ulcers, there was no physician order for enhanced barrier precautions (EBP) despite the presence of wounds on both feet. The Infection Prevention Nurse (IP) confirmed that EBP should have been ordered for this resident, as per facility policy, to ensure staff are aware of the necessary protective measures during care. Additionally, another resident with a history of cerebral infarction, pressure ulcer, muscle weakness, and sepsis was observed to have both contact precautions and EBP signage posted outside their isolation room. The IP stated that only the contact precautions sign should have been displayed due to the resident's MDRO status, as having both signs could cause confusion among staff regarding the appropriate personal protective equipment (PPE) to use. These findings were confirmed through observation, interview, and record review, and were not in accordance with the facility's own policies on EBP and transmission-based precautions.
Resident Room Size Below Regulatory Standards
Penalty
Summary
The facility failed to provide rooms that meet the required minimum square footage per resident. Specifically, rooms intended for multiple residents did not meet the standard of at least 80 square feet per resident, and single resident rooms did not meet the required 100 square feet. This deficiency was identified based on the physical measurements of resident rooms during the survey.
Clean Linen Stored Outside in Violation of Infection Control Policy
Penalty
Summary
The facility failed to follow its infection control policy regarding the storage of clean laundry. During two separate observations, two laundry carts containing clean linen and towels intended for residents were found stored in the facility's parking lot. Although the carts were covered with plastic, they remained outside for an extended period. The Maintenance Supervisor confirmed that the carts contained clean linen and explained that they were placed outside due to a lack of space inside the facility. The interim DON acknowledged that storing clean linen in the parking lot, even if covered, was unhygienic and constituted an infection control issue. Review of the facility's Laundry and Linen Policy indicated that clean linen should be stored and transported in a safe and aseptic manner, with carts covered and stored in designated areas inside the facility.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The facility failed to report an incident of elopement involving a resident to the state survey agency (SSA) as required by their own policy and federal or state regulations. The resident, who had diagnoses of encephalopathy and anoxic brain damage, was admitted with a documented need for close supervision due to impaired cognition and poor safety awareness, and was identified as an elopement risk. On the day of the incident, the resident eloped while a licensed vocational nurse was temporarily assisting another resident. The facility initiated a search and notified the police, the resident's family, the director of nursing, and the administrator, but did not notify the SSA. Interviews with the director of nursing and the administrator confirmed that the elopement was not reported to the SSA, with the administrator stating the event was not reported because the resident was eventually found. Review of the facility's policy on Unusual Occurrence Reporting indicated that such events, which affect the health, safety, or welfare of residents, must be reported to appropriate agencies within 24 hours. The failure to report the elopement resulted in a delay in the investigation of the incident and in ensuring the resident's safety.
Failure to Provide Required Supervision for Resident at Risk of Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident who was identified as an elopement risk. The resident, admitted with diagnoses including encephalopathy and anoxic brain damage, had a care plan in place that required constant monitoring and a one-to-one sitter due to impaired cognition and poor safety awareness. Despite these documented needs and interventions, the resident was left unsupervised at the facility's front entrance when the assigned staff member temporarily assisted another resident. During this period, the resident eloped from the facility and was later found at their home, 6.4 miles away. Interviews with facility staff confirmed that no one-to-one sitter was provided on the day of the incident, despite the care plan and prior assessments indicating this was necessary. The facility's policies on wandering, elopement, and resident supervision emphasized the importance of identifying at-risk residents and providing appropriate supervision, but these were not followed in this case. The deficiency resulted from the facility's failure to implement required supervision and safety measures for a resident at high risk for elopement.
Failure to Develop and Implement Nutrition Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan to address the nutritional and hydration needs of a resident who was admitted with diagnoses including Parkinson's disease, muscle weakness, and heart failure. The resident was assessed as having mild cognitive impairment, was dependent on assistance for multiple activities of daily living, and had an indwelling catheter. The nutritional assessment indicated the resident had variable oral intake, was underweight, and required additional calories. Despite these findings, no care plan was created to address the resident's nutritional needs. During interviews and record reviews, the DON confirmed that although the resident was receiving high protein supplements three times a day due to malnutrition, there was no care plan in place to monitor or evaluate the effectiveness of these interventions. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables for all residents, including those at risk for nutritional complications. The absence of a care plan meant the facility did not address or monitor the resident's nutritional and hydration needs as required.
Failure to Monitor and Address Resident's Nutritional and Hydration Needs
Penalty
Summary
The facility failed to adequately evaluate and monitor the nutritional and hydration needs of a resident with multiple medical conditions, including Parkinson's disease, muscle weakness, and heart failure. The resident was admitted with an indwelling catheter and was dependent on staff for most activities of daily living. A physician's order was in place to monitor the resident's input and output (I&O) for hydration, and the care plan included interventions to observe urine output and encourage fluid intake. However, review of documentation revealed that while fluid intake was recorded, urine output was not consistently documented every shift as required by the physician's order and facility policy. This lack of consistent documentation prevented staff from accurately assessing the resident's hydration status. Additionally, the registered dietitian (RD) initially assessed the resident's nutritional needs and recommended a fortified diet to provide additional calories due to the resident being underweight and at risk for weight loss and dehydration. Despite this recommendation, there was no evidence that the RD continued to evaluate the resident's nutritional needs after the initial assessment, and the resident was not provided with the fortified diet as recommended. The dietary supervisor confirmed that the resident did not receive the fortified diet, which could have contributed to inadequate nutritional intake. Interviews with facility staff, including the registered nurse supervisor and the director of nursing, confirmed that the required monitoring and documentation of I&O were not performed consistently. The RD also acknowledged that there was no follow-up or documentation after the initial assessment. Facility policies and job descriptions reviewed indicated that these actions were required, but they were not carried out, resulting in the facility's failure to meet the resident's hydration and nutritional needs.
Inadequate Night Shift Staffing Led to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff during the night shift on two consecutive days, resulting in a resident not receiving timely assistance with personal hygiene needs. The resident, who was admitted with muscle weakness, difficulty walking, and a high risk for falls, was dependent on staff for toileting and other activities of daily living. On the nights in question, only two CNAs were present to care for 48 residents after two scheduled CNAs called in sick and were not replaced. As a result, the resident had to wait for hours after activating the call bell before receiving help to change her pull-ups, leading to distress and dissatisfaction. The resident reported feeling annoyed and angry due to the long wait times for assistance. The facility's staffing policy requires sufficient numbers of staff to meet residents' needs according to their care plans, but this was not met on the nights in question. The Director of Staff Development acknowledged that the reduced staffing negatively affected the quality of care and contributed to staff burnout. The deficiency directly impacted the resident's psychosocial and physical well-being, as timely care was not provided.
Failure to Monitor Nutritional and Fluid Needs
Penalty
Summary
The facility failed to follow physician orders to evaluate a resident's nutritional and fluid needs, specifically for a resident with dysphagia, gastrostomy, and dementia. The resident was admitted with a high risk for aspiration, dehydration, and weight loss, and the care plan included nutritional assessment and follow-up by a registered dietitian (RD). However, the RD did not assess the resident in January and February, despite a significant weight loss of 11 pounds in five days. The RD acknowledged the lack of weekly weight variance interdisciplinary team meetings, which should have been conducted to discuss the resident's needs and laboratory results. Additionally, the facility did not monitor the resident's intake and output as ordered by the physician. The physician had ordered monitoring for 30 days, but the registered nurse supervisor could not find documentation of this monitoring. The director of nursing confirmed that the resident was receiving gastrostomy tube feeding with water flushes and emphasized the importance of monitoring intake and output to ensure proper absorption and adjustment to the feeding. The facility's policies and procedures required the RD to conduct comprehensive nutrition assessments and monitor residents' weight trends and hydration status. However, the RD failed to maintain accurate and timely documentation in the resident's medical records, as required by state and federal regulations. The facility's policies also required the dietitian to follow up with residents receiving enteral nutrition and make appropriate recommendations, which was not done in this case.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to provide necessary interventions to prevent complications for a resident receiving enteral nutrition through a gastrostomy tube (GT). The resident, who had diagnoses including dysphagia, gastrostomy, and dementia, was at high risk for aspiration related to tube feeding. The facility did not adhere to the physician's order to keep the resident's head of the bed elevated at 30 degrees or higher during feeding and for one hour after feeding had stopped. Additionally, the facility failed to check the tube placement before the initiation of formula, medication administration, and water flushing at least every eight hours. The deficiency was identified during a review of the resident's care plan and physician orders, which indicated the need for specific interventions to prevent aspiration. The director of nursing acknowledged the lack of documentation confirming adherence to these orders, with the last recorded instance of proper head elevation occurring several days prior. The nurse practitioner confirmed that improper positioning could lead to aspiration pneumonia, highlighting the importance of maintaining the prescribed head elevation during GT feeding. The facility's policy on enteral nutrition also emphasized the need for these precautions to mitigate the risk of aspiration.
Failure to Document Care Meeting in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically by not documenting a care meeting held with the resident's responsible parties. The resident, who had been admitted with conditions including dysphagia, a gastrostomy, and dementia, was assessed to have severely impaired cognitive skills and required substantial assistance with daily activities. Despite a meeting occurring on February 27, 2025, involving the resident's responsible party and facility staff, including a registered nurse supervisor, activity director, licensed vocational nurse, and social service designee, no documentation of this meeting was recorded in the resident's medical record. Interviews with facility staff confirmed that the meeting took place and included discussions about the resident's care plan and medications. However, the social service designee stated that the meeting was considered informal and thus was not documented. The director of nursing acknowledged that the meeting should have been documented as a care conference, in line with the facility's policy and procedures, which require all services and changes in a resident's condition to be recorded in the medical record. This oversight resulted in an incomplete and inaccurate medical record for the resident.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Behavioral Assessment
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, as evidenced by an incident involving two residents. Resident 1, who had a diagnosis of schizoaffective disorder and moderate cognitive impairment, exhibited new aggressive behavior by punching a staff member. Despite this incident, the facility did not implement its policy for behavior assessment, intervention, and monitoring, which required a thorough evaluation by the interdisciplinary team (IDT) to address Resident 1's changing behavioral symptoms. Five days after the initial aggressive incident, Resident 1 sexually abused Resident 2, a roommate with severe cognitive impairment and hemiparesis, by removing Resident 2's incontinent brief and inappropriately touching her. This incident was witnessed by a certified nursing assistant (CNA), who intervened and reported the abuse. The facility's failure to conduct a psychosocial evaluation and provide emotional support for Resident 1 after the initial aggressive behavior contributed to the subsequent abuse of Resident 2. Interviews with facility staff, including the Director of Nursing (DON), Social Service Director (SSD), and Quality Assurance Nurse (QA), revealed that the IDT did not meet to evaluate Resident 1's new behavior or develop individualized interventions. The SSD was unaware of Resident 1's aggressive behavior and did not conduct a psychosocial visit. The QA acknowledged the importance of IDT meetings to ensure the safety of residents and staff. The facility's policies on abuse prevention and behavior assessment were not followed, resulting in a failure to protect Resident 2 from abuse.
Failure to Timely Assess and Follow Up on Resident Fall
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who reported a fall. The resident, who was cognitively intact and had a history of respiratory failure, chronic pain syndrome, and anxiety disorder, reported falling from his bed at 4 a.m. on 12/8/24. Despite the resident's report of the fall and subsequent back pain, the facility did not assess the resident immediately, nor did they notify the resident's physician promptly. The resident had to contact his own doctor, who ordered an MRI, but the facility did not carry out this order in a timely manner. The resident's fall was initially reported to an LVN, who noted the incident but failed to document any assessment or follow-up actions in the progress notes. The LVN stated that she notified the resident's physician via text, but there was no documentation of this communication. The resident continued to experience back pain and expressed concerns about his condition, yet the MRI ordered by the physician was delayed by 19 days due to issues with obtaining authorization from the resident's health insurance. The facility's policies on change in condition and assessing falls were not followed, as the resident's fall was not properly assessed, documented, or communicated to the physician. The delay in conducting the MRI and the lack of immediate assessment and notification of the physician were significant deficiencies in the care provided to the resident, potentially delaying necessary treatment for injuries resulting from the fall.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to provide a safe and accident-free environment for a resident with visual impairment, a left above the knee amputation, and a history of falls. The facility did not follow the physician's order for visual hourly safety checks for fall prevention, nor did they review and update the resident's At Risk for Falls Care Plan after a fall and change in condition. This lack of adherence to the care plan and physician's orders contributed to the resident experiencing another fall, resulting in a laceration to the forehead and subsequent admission to the intensive care unit for an acute stroke. The resident was admitted to the facility with multiple diagnoses, including schizophrenia and visual impairment, and had a care plan initiated to minimize the risk of falls. However, the care plan had not been updated since its initiation, despite the resident's fall on a previous occasion. On the night of the incident, the resident was left unattended and fell from the bed, despite a warning from the roommate to the LVN that the resident was at risk of falling. The LVN failed to reposition the resident or conduct the required visual checks, as documented incorrectly in the Medication Administration Record (MAR). Interviews with staff and review of records revealed that the resident's care plans were outdated and did not reflect the resident's current high risk for falls. The facility's policies and procedures for fall risk assessment and care plan updates were not followed, leading to inadequate supervision and failure to implement necessary interventions, such as floor mats, which could have prevented the injury. The documentation errors and lack of timely updates to the care plan contributed to the resident's fall and subsequent injury.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of quetiapine fumarate (Seroquel), an antipsychotic medication, to a resident. The resident was admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood and muscle weakness. The care plan indicated the resident was to be informed about the risks and benefits of the medication regimen. However, the resident's informed consent was not obtained before the administration of the medication, as evidenced by the missing signature on the informed consent form. The resident, who was cognitively intact, reported not being informed about the medication and not signing any consent form. The Medication Administration Record showed that the resident was administered Seroquel multiple times without the necessary informed consent. The Director of Nursing confirmed the absence of the resident's signature on the informed consent form and acknowledged that consent should have been obtained prior to starting the medication. The facility's policy required documentation of informed consent before initiating psychotherapeutic drugs, which was not adhered to in this case.
Failure to Indicate and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to provide proper indication and monitoring for a resident who was started on the psychotropic medication Seroquel. The physician's order for Seroquel did not include the indication for its use or the targeted behavior and manifestation. Additionally, the informed consent form was incomplete, lacking the diagnosis and behavior for which the medication was ordered. The resident, who was admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood, was not monitored for adverse reactions such as lethargy, as required by the facility's policy. Interviews with facility staff revealed that the licensed vocational nurse (LVN) who obtained the Seroquel order from the psychiatrist acknowledged the omission of the indication and diagnosis in the order. The director of nursing (DON) confirmed that the reason for starting the resident on Seroquel and the targeted behavior were missing from the order, and that the resident should have been monitored for adverse reactions. The facility's policy on antipsychotic medication use mandates that residents receive such medications only when necessary and that nursing staff monitor and report any side effects or adverse consequences to the attending physician.
Failure to Provide Adequate Supervision and Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident with a high risk of falls, leading to a significant injury. The resident, who had a history of falls and was dependent on staff for toilet transfers, attempted to go to the bathroom unassisted and fell, resulting in a displaced intertrochanteric fracture of the right femur. The care plan for bowel and bladder incontinence, which required assistance every two hours, was not followed, and the resident was not provided with the necessary supervision. The resident's care plans were not updated or revised as required, contributing to the deficiency. The At Risk for Fall care plan had been resolved without a new plan in place, and the quarterly care plans were missing. The Director of Staff Development and the MDS coordinator acknowledged the lack of updates and revisions to the care plans, which were crucial for providing accurate guidance to staff and meeting the resident's needs. Interviews with staff revealed that the resident was confused, dependent on staff for mobility, and did not consistently use call lights. The facility's policy required frequent rounds and assistance, but these were not documented, and the two-hourly rounds for toileting assistance were not part of the facility's process. The Director of Nursing confirmed that the facility did not document the required rounds, which contributed to the resident's fall and subsequent injury.
Failure to Update Resident Care Plans Quarterly
Penalty
Summary
The facility failed to review, revise, and update the care plans quarterly for a resident, specifically addressing risks for falls, incontinence, and activities of daily living (ADL). The resident, who was readmitted with diagnoses including generalized muscle weakness, cognitive communication deficit, and chronic kidney disease, was found to be moderately confused and dependent on staff for mobility and toileting. Despite having a history of falls and incontinence, the care plans were not updated as required, with the last revision noted in September 2024, and no updates recorded for June 2024. Interviews with the Director of Staff Development, MDS Coordinator, and Director of Nursing confirmed the deficiency in updating the care plans. The facility's policy requires quarterly updates in conjunction with the Minimum Data Set (MDS) assessment, but this was not adhered to for the resident in question. The lack of updates in the care plans potentially exposed the resident to risks of recurrent falls, urinary tract infections, and a decline in functional ability.
Failure to Monitor and Evaluate Resident's Bladder Habits Leads to Fall and Injury
Penalty
Summary
The facility failed to properly monitor and evaluate a resident's bladder habits, leading to a deficiency in care. The resident, who was incontinent and dependent on staff for toilet transfer, was not monitored at regular intervals as required by the care plan. The care plan, initiated in March 2023, included interventions to assist the resident to the bathroom every two hours and to encourage participation in a bowel and bladder re-training program. However, there was no evidence of regular monitoring or evaluation of the resident's continence status, and the care plan was not reviewed or revised as needed. The resident, who had severe cognitive impairment and was dependent on staff for toileting and personal hygiene, attempted to go to the bathroom independently and fell, resulting in a displaced intertrochanteric fracture of the right femur. The facility's documentation indicated that the resident had a history of falls and was at high risk for potential falls, yet the care plan was not updated to address these risks adequately. The facility's policy required regular monitoring and evaluation of bladder habits, but this was not implemented, and the resident's continence status was not checked at regular intervals. Interviews with facility staff revealed that the resident did not have a routine toileting schedule, and staff conducted random checks instead of the required two-hour intervals. The Director of Nursing acknowledged that the facility did not document the two-hour rounds as required by the care plan. The MDS coordinator also confirmed that there was a deficiency in updating the resident's care plans, which contributed to the resident's fall and subsequent injury.
Failure to Investigate and Report Alleged Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, specifically a Certified Nursing Assistant (CNA). The incident involved a resident who alleged being slapped by the CNA. This allegation was supported by another resident who heard the slap and the victim's subsequent question about the slap. Additionally, another CNA reported hearing the slap and the resident's scream to a Registered Nurse (RN), who then reported it to the Director of Nursing (DON). Despite these reports, the facility did not properly acknowledge or investigate the allegations, nor did they report the incident to the necessary authorities such as the police, ombudsman, or Department of Public Health. The resident involved had moderate cognitive impairments and was mostly dependent on staff for activities of daily living. The facility's failure to investigate and report the incident was acknowledged by the RN, the Social Services Director, and the Facility Administrator, who admitted that the incident should have been treated as suspected abuse. The facility's policy on abuse prevention requires thorough investigation and reporting of such incidents, but there was no documented evidence of an investigation. The Facility Administrator, who was also the abuse coordinator, believed the DON had investigated the incident, but this was not substantiated with documentation.
Inadequate Supervision and Equipment Inspection Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe operation of a hoyer lift during a resident transfer, resulting in an injury. Certified Nursing Assistant (CNA) 2 did not properly control the hoyer lift, causing it to lower quickly and hit Resident 2 in the face, leading to a bruise on the right eye. The incident occurred while transferring Resident 2, who was mostly dependent on staff for activities of daily living, from the bed to a wheelchair. Resident 2, who was cognitively intact and had the capacity to understand and make decisions, reported the incident, but the facility did not conduct a thorough investigation or inspect the hoyer lift for malfunctions. Additionally, the facility did not adequately follow up on the incident. Registered Nurse (RN) 1 observed the bruise but did not investigate further, relying on existing progress notes. The Facility Administrator also did not probe the incident further, assuming that the nursing staff had investigated. This lack of follow-up and failure to inspect the hoyer lift for malfunctions after the incident contributed to the deficiency in ensuring a safe environment free from accident hazards.
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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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