Healthcare Center Of Orange County
Inspection history, citations, penalties and survey trends for this long-term care facility in Buena Park, California.
- Location
- 9021 Knott Ave, Buena Park, California 90620
- CMS Provider Number
- 055674
- Inspections on file
- 28
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Healthcare Center Of Orange County during CMS and state inspections, most recent first.
A resident with a documented history of falls had a care plan that included use of a yellow wristband under the facility’s Falling Star Program to indicate high fall risk. Despite this, surveyors observed the resident in bed without the yellow wristband. During record review and interviews, an RN confirmed the prior falls and acknowledged that the care plan required both a door star and a yellow wristband, and further verified that the wristband was not in place at the time of observation.
A resident with physician orders for continuous bilateral heel offloading using pillows and heel protectors was repeatedly observed lying in bed with both heels resting on the mattress. A CNA caring for the resident reported not knowing whether there were orders for heel protectors or heel offloading. An LVN later reviewed the record, confirmed that the resident’s heels should be offloaded at all times while in bed, and acknowledged that the resident had no current heel pressure injuries.
A resident with an indwelling urinary catheter was observed on multiple occasions with the urinary drainage bag resting on the floor, despite a physician’s order to maintain the bag below the bladder and staff descriptions that it should hang from the bedframe with a basin underneath to prevent contact with the floor. A CNA confirmed the bag was touching the floor during observation and an RN later described the expected positioning, demonstrating that appropriate catheter care and positioning were not consistently maintained to prevent UTIs.
A resident with severe cognitive impairment and a history of recent falls was repeatedly observed asleep in bed with bilateral upper grab rails elevated. The care plan, updated after the falls, included side rails as grab bars for fall prevention and assistance with repositioning, but the bed rail assessment documented that side rails or assist bars were not indicated, and no bed rail entrapment risk assessment was found. Staff interviews confirmed that the resident used the grab rails for turning and repositioning and that the care plan called for grab bars despite the assessment indicating otherwise, resulting in a deficiency for failing to ensure safe and properly assessed side rail use.
A resident with documented lack of decision-making capacity was discharged to an acute care hospital after experiencing vomiting and distress when GT feeding was resumed and 911 was called. After this discharge, an SSA later called the resident’s family to schedule a care plan meeting based on the MDS calendar and documented this call in the progress notes, despite the resident no longer being in the facility. The DON and SSA confirmed that this entry was made after discharge, resulting in an inaccurate medical record.
A resident with a history of brain injury, who was nonverbal and bedbound, experienced an unwitnessed fall resulting in a subdural hematoma after staff failed to investigate a family grievance about the resident's position near the bed edge and did not update the care plan or accurately assess fall risk. Staff were aware of the resident's behavior of dangling legs off the bed, but this was not documented or addressed prior to the incident.
A resident with a history of brain injury and on anticoagulant therapy experienced an unwitnessed fall resulting in a head injury. An LVN delayed contacting 911, first attempting to arrange transport through regular ambulance services despite physician orders for hospital evaluation. The resident was eventually transferred and diagnosed with a small subdural hematoma. Facility leadership confirmed that 911 should have been contacted immediately in such circumstances.
Two residents did not receive scheduled medications as prescribed, and staff failed to accurately document medication administration on the MAR. In one case, medications were recorded as given after a resident had been transferred to a hospital, and in both cases, blank spaces indicated missed doses. The DON and LVN confirmed these documentation and administration failures during interviews.
A resident experienced a fall and was subsequently assessed as high risk for falls, but the care plan was not updated to reflect this increased risk. Review of records and staff interviews confirmed that the care plan continued to indicate only a moderate fall risk, contrary to facility policy requiring updates when a resident's condition changes.
Two residents had incomplete and inaccurate medical records, including fall risk assessments with missing information and incorrect documentation of medication classes taken. Staff interviews confirmed these documentation issues, which did not meet the facility's policy for complete and accurate records.
Three cognitively intact residents experienced ongoing issues with non-functioning TV channels, their preferred activity, despite repeated complaints to staff and documentation in facility records. The facility failed to address these concerns in individualized care plans or provide effective follow-up, resulting in unmet activity needs as required by policy.
The facility did not maintain enough portable oxygen tanks for all residents with continuous supplemental oxygen orders, leaving several without access in an emergency. Additionally, a resident's BiPAP machine and stand were found unclean and cluttered with trash and an unlabeled urinal, with no documentation of required cleaning, as confirmed by staff and the DON.
The facility did not include in its assessment the number of portable oxygen tanks needed to evacuate all residents with continuous oxygen orders during an emergency. At the time of review, 55 residents required continuous oxygen, but only 46 full portable tanks were available, leaving the facility unable to provide for all affected residents during an evacuation.
Residents repeatedly reported during council meetings that call lights were not answered in a timely manner, with some waiting up to 20-30 minutes for assistance. Despite facility policy requiring documentation and follow-up on such concerns, there was no evidence that the nursing department addressed or resolved the issue. The Activities Director and DON confirmed the lack of documented response and ongoing nature of the problem.
A resident was observed eating lunch in her room when a pest was found floating in her milk. The resident reported feeling nauseated and refused to drink the milk due to the contamination. An LVN confirmed the presence of the insect and removed the milk, while the Central Supply Supervisor acknowledged the issue after being informed.
Three residents received psychotropic medications without documented non-pharmacological interventions as required by facility policy and physician orders. One resident also did not have accurate orthostatic blood pressure monitoring as ordered. Nursing staff and the DON confirmed that non-pharmacological interventions were not routinely provided or documented prior to medication administration.
A resident with complex medical needs, including wound care and an indwelling urinary foley catheter, was discharged home without documented discharge instructions for medication management, wound care, or catheter care. The discharge instruction form was left blank, and there was no evidence that the resident's representative received the necessary information, as confirmed by staff interviews and record review.
A resident with updated diagnoses of depression, schizoaffective disorder, bipolar disorder, and anxiety disorder was not properly assessed through the PASARR program, as the facility failed to complete a new PASARR after the resident's medical record and MDS assessment reflected these mental health conditions and related medications.
A resident with Clostridium difficile colitis and an order for contact isolation precautions did not receive the required infection control measures. Staff followed an incorrect Enhanced Barrier Precautions sign, and a CNA entered the room without proper PPE, indicating a failure to implement the care plan as ordered.
Multiple residents with impaired ROM and mobility did not receive restorative nursing assistant (RNA) services as ordered by physicians, including PROM/AAROM exercises, orthotic device application, and ambulation assistance. Documentation showed missed sessions without clinical justification, and staff interviews confirmed that RNAs were often reassigned to CNA duties, resulting in the failure to provide required restorative care.
A resident experienced a significant weight loss over a short period, but staff did not reassess the weight, notify the physician, or document follow-up as required by facility policy. The care plan noted nutritional risks but did not specify thresholds for significant weight change, and the DON confirmed the lack of monitoring and documentation after the event.
Three residents with gastrostomy tubes did not have appropriate physician-ordered diets, and two residents were observed receiving enteral feedings with the head of bed elevated less than 30 degrees, contrary to orders and policy. Additionally, a resident with dysphagia received medications ordered and documented as oral, despite being unable to take anything by mouth. Nursing staff and leadership confirmed these deficiencies during interviews and record reviews.
A resident's peripheral IV (PIV) site was found unlabeled and not discontinued after IV antibiotics were stopped, contrary to facility policy requiring labeling and removal if not in use. Nursing staff and the DON confirmed there were no current IV orders and acknowledged the PIV should have been removed after therapy ended.
A resident receiving enoxaparin for DVT prophylaxis did not have injection sites rotated as ordered by the physician and required by facility policy. Nursing staff confirmed that multiple injections were given in the same abdominal area over several days, and acknowledged that the sites should have been rotated to comply with orders and standard practice.
A pharmacist did not identify or report a missing dose in a physician's order for docusate sodium during the monthly drug regimen review. A resident received one 100 mg tablet twice daily via GT based on available stock, without dose clarification from the physician. The MAR and order both lacked a specified dose, and the issue was not detected by the pharmacist as required by facility policy.
Surveyors observed that two nurses failed to properly verify and administer medications to two residents, resulting in a medication error rate of 14.29%. One nurse administered a medication without a specified dose, while another did not ensure full dosages were given, as evidenced by residue left in medication cups after administration via GT. The facility's policies requiring dose verification and complete administration were not followed, and the DON acknowledged these deficiencies.
Surveyors identified multiple deficiencies in medication storage and security, including a resident found with an unlabeled medicine cup containing Betadine at bedside, expired medications present in two medication carts, and an LPN leaving a medication cart unlocked while unattended. The DON and staff confirmed these findings, indicating noncompliance with facility policies and pharmacy service requirements.
Surveyors found that food safety and sanitation guidelines were not followed, including the use of a can opener with a stripped blade, frying pans and a strainer with visible residue, an opened box of gloves stored on clean plates, and food residue in a resident-accessible microwave. These deficiencies were confirmed by the Dietary Service Supervisor, Kitchen Dishwasher, LVN, and DON, and affected 39 residents who consumed food prepared in the kitchen.
Surveyors observed overflowing dumpster bins with lids unable to close, scattered trash on the ground, and seven sharps containers left on top of biohazard bins instead of being properly disposed. Additional non-trash items were found improperly stored near the generator. The Central Supply Supervisor and DON confirmed these sanitation lapses.
Two residents experienced deficiencies in medical record documentation: one had an outdated NPO order that was not discontinued after a new diet order was implemented, and another had repeated blood pressure readings documented from an arm with a hemodialysis AV shunt, contrary to facility policy. These issues were confirmed by nursing staff and the DON.
Multiple failures in infection prevention and control were identified, including improper implementation of contact isolation for a resident with C. difficile, lack of dedicated equipment, missing signage for enhanced barrier precautions, improper handling of soiled linens, and inadequate hand hygiene by staff. The facility also lacked a comprehensive water management program as required by policy and regulation.
A resident who had previously received only the PPSV23 vaccine was not offered a dose of PCV 20, PCV 21, or PCV 15 as recommended by current CDC guidelines. Facility policy required assessment and offering of pneumococcal vaccines, but the resident's records and immunization registry showed no evidence of the required vaccine being offered or administered. The IP relied on outdated guidance and did not ensure the resident's vaccination status was current.
Surveyors found that the medication refrigerator used for storing residents' medications had thick ice buildup and was not being defrosted frequently enough, as confirmed by an RN and the DON. Additionally, required nightly quality control checks for a glucometer on a medication cart were not documented on two occasions, despite staff stating these checks should be performed and recorded.
Three residents using bilateral side rails were found to have bed system gaps exceeding FDA-recommended limits, with measurements in multiple entrapment zones above the allowable maximum. The Central Supply Supervisor confirmed the out-of-range measurements and lack of corrective documentation, and there was no regular maintenance schedule or log for bed safety. Facility leadership acknowledged these findings.
Two residents had deficiencies in their MDS discharge assessments: one was incorrectly documented as being discharged to a hospital instead of a board and care facility, and another had a missing discharge assessment despite being discharged home under hospice care. Both the MDS Coordinator and DON confirmed these documentation errors.
A resident's drug regimen was not free from unnecessary medications as metoprolol and hydralazine were administered outside of the physician's ordered parameters. The medications were given despite the resident's blood pressure and heart rate being below the specified thresholds. Interviews with the LVN and DON confirmed the failure to adhere to the physician's orders, acknowledging the potential for negative outcomes.
A resident's request not to have a specific CNA assigned for ADL care was not consistently honored, compromising her dignity and respect. Despite a complaint and facility policy, the CNA was assigned to the resident during a night shift, leading to an incident where the CNA changed the resident's incontinence brief against her initial wishes.
A resident dependent on a respirator fell and sustained a head injury and cervical fracture when a CNA, unaware of the two-person assistance requirement, attempted to turn the resident alone. The facility's failure to follow the care plan led to the incident.
The facility failed to ensure proper storage, labeling, and disposal of medications in multiple medication carts and rooms. Expired medications, improper storage of antiseptics with medications, and mixing of oral and external use medications were observed. Unauthorized personnel were also found in the medication room without supervision, and required signatures on medication destruction forms were missing.
The facility failed to ensure that 36 of 94 residents received the proper diets and portion sizes as per the facility's menus. Deviations included not following the BBQ Chicken puree recipe, incorrect portion sizes for ground BBQ chicken and potato salad, and using bottled BBQ sauce instead of homemade BBQ sauce for CCHO diets. These issues were confirmed through observations and interviews with the RD and other staff.
The facility failed to ensure that residents on mechanically altered diets received food in a form that met their individual needs. Pureed bread was not prepared correctly, and two residents received incorrect diet textures. These deficiencies were confirmed through observations and interviews with the Dietary Services Supervisor, Registered Dietitian, and Speech Language Pathologist.
The facility failed to ensure complete entrapment assessments and measurements for six residents using side rails, leading to potential risks. The Maintenance Director and DON acknowledged inconsistent assessments and lack of documentation, contrary to the facility's policy requiring routine inspections to identify entrapment risks.
The facility failed to provide two residents with the required Notice of Medicare Non-coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055, potentially preventing them from making informed decisions regarding their Medicare services.
The facility failed to implement restraint-free periods for two residents as required by their care plans and physician orders. Observations and interviews revealed that the mittens were not consistently released for the required duration, and there was no documentation of the release periods or assessments of the residents' skin, circulation, and mobility.
The facility failed to develop a comprehensive care plan for a resident who stored perishable and nonperishable food items in their room, contrary to facility policies. An LVN confirmed the absence of a care plan addressing this issue, highlighting a lack of individualized care.
An LVN failed to follow the facility's policy and procedure for administering Flonase Allergy nasal spray to a resident, potentially impacting the resident's health due to malabsorption and reduced medication effectiveness. The LVN did not provide necessary instructions during administration, assuming the resident already knew how the medication worked.
The facility failed to ensure a resident's heel protector boots were applied as per the physician's order for wound management and prevention. During an observation and interview, it was verified by both a CNA and an LVN that the resident was not wearing the heel protectors while in bed.
The facility failed to provide the RNA services as ordered by the physician for a resident, leading to missing documentation and potential decline in the resident's range of motion and mobility. The physician's orders included PROM exercises and the application of extension splints, which were not documented as performed on specific dates. The DON confirmed the findings and stated that missed exercises could be made up on a later date.
A resident identified as high risk for falls did not have the required bilateral floor mats in place, despite a physician's order and care plan. This failure was confirmed through observations and interviews, placing the resident at risk for serious injury.
The facility failed to maintain IV accesses and develop care plans for two residents with PICC lines. Necessary measurements and physician's orders were not documented, and specific care plans were not formulated. These deficiencies were confirmed through observations, interviews, and medical record reviews.
Failure to Implement Care-Planned Fall Prevention Wristband
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for fall prevention for one resident identified as high risk for falls. The facility’s Falls – Clinical Protocol, revised 3/2018, states that staff and the physician will identify pertinent interventions to prevent subsequent falls and address the risks of clinically significant consequences of falling. The resident was readmitted to the facility and had documented falls on two occasions, with progress notes indicating the resident was found on the floor on the left side of the bed on one date and kneeling on the floor mat next to the left side of the bed on another date. In response to these events, the resident’s plan of care was updated with a problem addressing the actual fall, and interventions included providing a yellow wristband per the facility’s Falling Star Program to indicate high fall risk and history of falls. On the survey date, the resident was observed in bed and asleep and was not wearing the yellow wristband required by the care plan and the Falling Star Program. During a concurrent medical record review and interview, an RN confirmed that the resident had fallen on two prior occasions and verified that the resident’s fall care plan interventions included having a star by the resident’s name on the door and a yellow wristband to indicate high fall risk. A subsequent observation with the same RN confirmed that the resident did not have a yellow wristband in place. This lack of implementation of the care-planned intervention constituted the identified deficiency.
Failure to Follow Heel Offloading Orders for Pressure Injury Prevention
Penalty
Summary
Surveyors identified a deficiency in pressure injury prevention care for Resident 3, who was observed multiple times on 4/14/26 lying in bed asleep with both heels in direct contact with the bed surface. Medical record review showed physician orders dated 11/5/25 to offload bilateral heels with pillows at all times while in bed for skin maintenance, and an additional order dated 11/29/25 to apply bilateral heel protectors at all times for skin management, with allowance to remove them during resident care. Despite these orders, Resident 3’s heels were not offloaded during observations at 0900, 0911, 1227, and 1243 hours. During an interview at 1243 hours, the CNA providing care stated she was not sure whether there was a physician order to apply heel protectors or offload the resident’s heels. At 1255 hours, an LVN, after reviewing the medical record, confirmed that the resident’s heels should be offloaded from the bed with a pillow or heel protectors per the physician’s orders and obtained heel protectors for the resident. The LVN also stated that Resident 3 did not have any current skin issues or pressure injuries on her heels.
Improper Positioning of Indwelling Urinary Catheter Drainage Bag
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and services to prevent UTIs for a resident with an indwelling urinary catheter. During observations on 4/14/26 at 0834 and 0845 hours, the resident was seen in bed with an indwelling urinary catheter connected to a urinary drainage bag that was resting on the floor. A pink basin was also observed underneath the resident’s bed. Medical record review showed the resident had been admitted on a prior date and had a physician’s order, dated 3/19/26, directing that the indwelling urinary catheter drainage bag be maintained below the bladder at all times. At 0917 hours on the same day, a CNA confirmed during an observation and interview that the resident’s urinary drainage bag was touching the floor and that a pink basin was under the bed. The CNA then repositioned the drainage bag by placing its hook on the bedframe and discarded the basin. Later, at 1350 hours, an RN stated that when the bed is in the lowest position, the drainage bag should still be hanging from the bedframe, and that a pink basin should be placed underneath the drainage bag to prevent the bag and catheter tubing from touching the floor. These observations and interviews demonstrated that the resident’s catheter drainage bag was not maintained off the floor as ordered and as described by nursing staff as proper positioning.
Inconsistent Bed Rail Assessment and Use After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s use of side rails was consistent with the facility’s bed safety policy and the resident’s own assessments and care plan. The facility’s policy required the IDT to assess the resident’s sleeping environment, consider safety, medical conditions, comfort, freedom of movement, and input from the resident/family, and to use side rails only when needed to manage a medical symptom or to assist with repositioning or transfers when no other reasonable alternatives were identified. Surveyors observed the resident on multiple occasions lying in bed asleep with bilateral upper grab rails elevated. The resident’s MDS showed severe cognitive impairment, no impairment to upper or lower extremities, and a need for staff supervision for bed mobility. Progress notes documented that the resident was found on the floor on one occasion and kneeling on a floor mat on another occasion. Following these falls, the resident’s plan of care was updated with a problem addressing an actual fall, and the interventions included providing side rails to be used as grab bars. However, the resident’s Bed Rail Assessment dated the same month indicated that side rails or assist bars were not indicated for this resident, and there was no documentation of a bed rail entrapment risk assessment being conducted at that time. During interviews, a CNA confirmed that the resident used the grab rails to hold on when turning and repositioning, and an RN confirmed that the fall care plan interventions included grab bars while also verifying that the bed rail assessment showed grab rails were not indicated. This inconsistency between the care plan, the bed rail assessment, and the actual use of side rails led to the cited deficiency for failing to ensure the resident was free from accident hazards related to side rail use.
Inaccurate Medical Record Entry After Resident Discharge
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident when documentation was entered after the resident had been discharged. The resident had been admitted to the facility and later discharged to an acute care hospital after experiencing vomiting and distress when GT feeding was resumed; 911 was called and the resident was transferred. The resident’s H&P dated 10/31/25 documented that the resident had no capacity to understand and make decisions. Despite the resident’s discharge to the hospital on 12/5/25, a progress note dated 12/14/25 at 1724 hours showed that the SSA documented calling the resident’s family member to schedule a care plan meeting. During interviews and concurrent closed record reviews, the DON and SSA confirmed that the resident had been discharged on 12/5/25 and that the SSA nonetheless documented the care plan scheduling call in the resident’s progress notes. The SSA stated she based care plan meeting schedules on the MDS calendar and would check the current census before calling families, but verified that she had called and left a voicemail for the resident’s family and recorded this in the chart after discharge, making the medical record inaccurate.
Failure to Prevent Accident Hazards and Update Care Plan After Grievance
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident was free from accident hazards, resulting in an unwitnessed fall and subsequent injury. The resident, who was nonverbal, bedbound, and dependent on staff for all mobility and hygiene needs, had a history of traumatic brain injury, anoxic brain damage, and was on multiple medications including anticoagulants. Despite a family member's grievance about the resident being positioned near the edge of the bed and the behavior of dangling legs off the bed, the facility did not adequately investigate the concern or implement additional interventions to address the identified risk. The facility's documentation showed that the grievance was received and an in-service on proper positioning was conducted for staff, but there was no evidence of a thorough investigation or individualized interventions for the resident. The fall risk assessment for the resident was found to be inaccurate, as it did not account for all relevant medication classes, resulting in an incorrect fall risk score. Staff interviews confirmed that the resident frequently dangled his legs over the bed and slid down on the mattress, but this behavior was not documented in the medical record or addressed in the care plan prior to the fall. The care plan for the resident included general fall prevention measures but was not updated to reflect the specific risk of the resident's behavior of hanging his legs over the bed, even after the family member's grievance. The lack of accurate assessment, failure to update the care plan, and insufficient investigation of the grievance led to the resident experiencing an unwitnessed fall, sustaining a subdural hematoma, and requiring hospitalization.
Delayed Emergency Response After Resident Fall with Head Injury
Penalty
Summary
A licensed vocational nurse (LVN) delayed contacting emergency services after a resident, who was on anticoagulant therapy and had a history of anoxic brain damage, diffuse traumatic brain injury, and epilepsy, experienced an unwitnessed fall and sustained a bump on the forehead. The LVN initially assessed the resident and, after consulting with the physician, was instructed to transfer the resident to an acute care hospital for evaluation. However, instead of immediately calling 911, the LVN first attempted to arrange transport through regular ambulance services, which both advised her to contact 911 due to the resident's use of blood thinners and the presence of a head injury. The delay in contacting 911 resulted in a late transfer of the resident, who was eventually transported to the hospital where a CT scan revealed a small right frontal subdural hematoma. Interviews with facility staff, including the Director of Nursing (DON), confirmed that the appropriate protocol in such cases would have been to contact 911 immediately, especially given the resident's anticoagulant use and head injury. The failure to promptly provide the necessary care and services as ordered and in accordance with the resident's needs constituted a deficiency in maintaining the resident's highest practicable well-being.
Failure to Administer and Accurately Document Medications for Two Residents
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two out of three sampled residents, as evidenced by missed and improperly documented medication administration. For one resident with complex medical conditions including anoxic brain damage, epilepsy, and chronic respiratory failure, the Medication Administration Record (MAR) showed multiple instances where scheduled medications were not documented as given. These included antiseizure medications, muscle relaxants, supplements, and other critical drugs. Additionally, the MAR indicated that several medications were documented as administered on dates when the resident was not present in the facility, having been transferred to an acute care hospital. Interviews with facility staff, including an LVN and the DON, confirmed that blank spaces on the MAR indicated medications were not administered, and that check marks were used to indicate administration. The DON verified that the resident was not in the facility during the times some medications were documented as given, confirming inaccurate documentation. The facility's policies required medications to be administered as prescribed and for staff to accurately document administration or reasons for withholding medications, which was not followed in these cases. A second resident, with diagnoses including epilepsy and carotid artery stenosis, also had missing documentation for scheduled medications on specific dates. These included artificial tears, blood thinners, supplements, and antihypertensive medications. The DON confirmed that the MAR lacked evidence of administration for these medications and acknowledged that blank spaces meant the medications were not given. The failures in medication administration and documentation were verified through medical record review and staff interviews.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plan for one resident after a fall incident. According to the facility's policy, care plans are to be updated as residents' conditions change. Medical record review showed that the resident was found on the floor after a fall and was subsequently assessed as being at high risk for falls. However, the care plan continued to reflect only a moderate risk for falls and was not updated to indicate the increased risk following the incident. This deficiency was confirmed through interviews with both an LVN and the DON, who acknowledged that the care plan had not been revised to reflect the resident's high fall risk after the event. The failure to update the care plan as required was based on direct review of the resident's records, facility policy, and staff interviews, with no evidence that the care plan was revised to address the resident's changed condition after the fall.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that medical records for two of three sampled residents were complete and accurate, as required by their own policies and accepted professional standards. For one resident, fall risk assessments contained blank entries in critical sections such as systolic blood pressure, vision status, and ambulation on multiple assessment dates. For another resident, the fall risk evaluation was inaccurate regarding the number of medication classes being taken, as the resident was documented as taking fewer classes of medications than were actually prescribed and administered according to the Medication Administration Record (MAR). These deficiencies were confirmed during interviews with facility staff, including an LVN and the Director of Nursing, who acknowledged the incomplete and inaccurate documentation. The facility's policy on charting and documentation requires that records be objective, complete, and accurate, but this standard was not met for the residents in question, potentially impacting the assessment of their care needs.
Failure to Provide Individualized Activity Program and Maintain Preferred Activities
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of three sampled residents, as required by its own policies and procedures. All three residents were cognitively intact and had clearly documented preferences for self-directed activities, particularly watching television, which was identified as very important to their well-being. Despite repeated complaints and grievances regarding non-functioning TV channels, the facility did not ensure that the residents' preferred activities were consistently available. Observations and interviews revealed that the residents experienced ongoing issues with their TVs, including missing or non-working channels for extended periods. Residents reported these problems to various staff members, including nursing staff, the Maintenance Director, and the Administrator, but the issues persisted. Facility documentation, such as grievance reports and Resident Council minutes, confirmed that the TV channel problems were a recurring concern and had not been resolved to the residents' satisfaction. The Maintenance Director and Administrator acknowledged the ongoing nature of the problem and the lack of effective resolution, with maintenance staff only attempting to reset TVs after complaints and no evidence of timely or comprehensive follow-up. Medical record reviews and staff interviews further confirmed that the residents' activity care plans did not address their TV concerns, and there was no documentation of care plan meetings or interdisciplinary discussions to resolve the issue. The facility's own policies required regular activity evaluations and individualized care planning based on residents' preferences, but these were not implemented in practice. The lack of a functioning TV, as a preferred activity, was not addressed in the residents' care plans, and staff did not provide adequate assistance or follow-up to ensure the residents' needs and interests were met.
Failure to Maintain Adequate Oxygen Supply and Clean Respiratory Equipment
Penalty
Summary
The facility failed to provide adequate respiratory care by not maintaining a sufficient number of portable oxygen tanks for residents with physician orders for continuous supplemental oxygen therapy. On the date of the survey, there were 55 residents with active orders for continuous supplemental oxygen, but only 46 portable oxygen tanks (43 E tanks and three H tanks) were available on site. This shortfall was confirmed by the respiratory therapist, who acknowledged that in the event of an emergency requiring evacuation, there would not be enough portable oxygen tanks to meet the needs of all residents requiring continuous oxygen. Additionally, the facility did not ensure that respiratory equipment was maintained in a clean and sanitary condition for a resident using a BiPAP machine. The BiPAP machine basket and stand were observed to be overflowing with trash, used facial tissues, empty soda cans, and an unlabeled urinal. The resident reported that he had requested staff to clean the BiPAP machine, but it had not been done. There was no documentation in the medical record, medication administration record (MAR), or treatment administration record (TAR) indicating that the BiPAP machine had been cleaned as required by facility policy. Interviews with nursing staff confirmed that the BiPAP machine should have been kept clean for infection prevention and that the urinal should have been labeled and not stored on the BiPAP stand. The Director of Nursing verified the findings, and staff could not provide evidence that the required cleaning had occurred, despite facility policy outlining specific cleaning procedures for such equipment.
Failure to Assess and Maintain Adequate Portable Oxygen Supply for Emergency Evacuation
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for the competent care of residents requiring continuous supplemental oxygen therapy during both routine operations and emergencies. Specifically, the facility assessment did not include information on the number of portable oxygen tanks needed to safely evacuate all residents with active physician orders for continuous oxygen in the event of an emergency, such as an earthquake. The assessment only indicated that central supply staff monitored and replenished emergency supplies but lacked details on the specific oxygen tank requirements for evacuation scenarios. At the time of review, there were 55 residents with active orders for continuous supplemental oxygen—51 in the subacute unit and four in the skilled nursing unit. However, the facility's inventory consisted of only 46 full portable oxygen tanks (43 E tanks and three H tanks), which was insufficient to meet the needs of all residents requiring continuous oxygen during an emergent evacuation. The Assistant Administrator confirmed that previous assessments had included this information, but the current assessment did not, resulting in a failure to ensure adequate resources for safe evacuation.
Failure to Address Resident Council Concerns Regarding Call Light Response
Penalty
Summary
The facility failed to address concerns raised by residents during Resident Council meetings regarding untimely responses to call lights. According to the facility's policy, concerns discussed in Resident Council meetings should be documented using a Resident Council Response Form, communicated to the relevant department within 72 hours, and resolved within a specified timeframe. However, review of Resident Council minutes from two separate meetings showed repeated complaints that call lights were not answered promptly, sometimes taking up to 20-30 minutes, and that nursing staff instructed residents to turn off their call lights with promises to return, but did not follow through. There was no documentation indicating that these concerns were addressed or resolved by the nursing department. Interviews with residents confirmed that the issue persisted and had not been resolved, with residents continuing to experience long wait times for assistance with basic needs such as toileting or retrieving items. The Activities Director acknowledged that the concerns had not been resolved and was unable to provide documentation of the required response forms or evidence of communication with the nursing staff. The DON confirmed the expectation that concerns should be communicated and addressed within the policy's timelines, but acknowledged the ongoing nature of the issue.
Pest Contamination in Resident's Food
Penalty
Summary
A deficiency was identified when a resident was observed sitting on her bed eating lunch in her room, and a pest was seen floating on the surface of her milk. The resident reported that she set her milk aside after noticing the bug, expressed feeling nauseated, and stated she would not drink the milk because of the contamination. She also mentioned having seen bugs flying around previously, though not landing on her food. A licensed vocational nurse (LVN) confirmed the presence of the insect in the milk and removed the cup from the room. The Central Supply Supervisor indicated that pest control is conducted monthly and was not previously aware of pest concerns in residents' rooms, but acknowledged the findings when informed.
Failure to Implement Non-Pharmacological Interventions and Accurate Monitoring for Psychotropic Medication Use
Penalty
Summary
Surveyors identified that the facility failed to prevent the use of unnecessary psychotropic medications and did not implement required non-pharmacological interventions for three residents. For one resident, aripiprazole and trazodone were administered daily for bipolar disorder and depression, respectively, but there was no documented evidence that non-pharmacological interventions were attempted as required by facility policy. Additionally, the resident's orthostatic blood pressure monitoring, as ordered by the physician to monitor for medication side effects, was not accurately completed or documented in the Medication Administration Record (MAR). Another resident received risperidone for schizophrenia and lorazepam for anxiety, with frequent episodes of anxiety and psychotic behavior documented. The care plan included interventions such as tallying anxiety behaviors and approaching the resident calmly, but review of the MAR and progress notes showed no documentation that non-pharmacological interventions were implemented prior to administering these medications, except for one instance where distraction was used alongside medication. The care plan also required review of behaviors and alternate therapies, but this was not consistently documented. A third resident was prescribed escitalopram for depression, with daily monitoring of depressive symptoms ordered. Despite documentation of multiple episodes of depression, there was no evidence in the MAR or progress notes that non-pharmacological interventions were provided before administering the antidepressant. Interviews with nursing staff and the DON confirmed that non-pharmacological interventions were not routinely provided or documented for residents on psychotropic medications, contrary to facility policy and physician orders.
Failure to Document and Provide Discharge Instructions for Resident
Penalty
Summary
A deficiency was identified when the facility failed to document and provide discharge instructions for one of three sampled residents reviewed for closed records. The facility's policy requires that details of a resident's transfer or discharge be documented in the medical record and that appropriate information be communicated to the receiving health care provider. However, for this resident, the Discharge Instruction Form was found to be completely blank, with no information provided in any of the required sections, including patient information, responsible parties, medication education, wound care, indwelling urinary foley catheter care, and signatures. The resident in question had a history of complex medical needs, including an indwelling urinary foley catheter, multiple wound care orders, and was discharged to home with family and home health services. The medical record review showed that the resident lacked decision-making capacity, and the family member was the legally recognized decisionmaker. Despite physician orders specifying the need for home health services for PT/OT/ST, RN/LVN services for medication management, wound care, and catheter care, there was no documentation that these instructions were communicated to the resident's representative at discharge. Interviews with facility staff, including an LVN and the Medical Records Coordinator, confirmed that the discharge instructions form should have been completed and provided to the resident's representative. The absence of documentation for medication management, wound care, and catheter care instructions, as well as the lack of signatures to confirm receipt by the legally recognized decisionmaker, was verified by both staff and the Director of Nursing.
Failure to Update PASARR Assessment for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate an assessment with the Pre-Admission Screening and Resident Review (PASARR) program for a resident who had updated diagnoses of depression, schizoaffective disorder, bipolar disorder, and anxiety disorder. Upon admission, the PASARR Level I Screening incorrectly indicated that the resident did not have a serious diagnosed mental disorder and was not prescribed psychotropic medications for serious mental illness. However, subsequent medical record reviews and the Minimum Data Set (MDS) admission assessment documented active diagnoses of anxiety, depression, and schizophrenia, as well as the use of antipsychotic, antianxiety, and antidepressant medications. Despite these updated diagnoses and medication orders, the facility did not complete a new PASARR assessment to reflect the resident's current mental health status and treatment needs. The oversight was confirmed during an interview and medical record review with the MDS Assistant, who acknowledged that a new PASARR should have been completed when the resident's diagnoses and medications were updated in the medical record and MDS assessment.
Failure to Implement Contact Isolation Precautions for C. difficile
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident who had a physician's order for contact isolation precautions due to Clostridium difficile colitis. The resident was receiving Vancomycin for this condition, and the care plan included interventions for contact isolation. However, during observation, a sign for Enhanced Barrier Precautions (EBP) was posted at the entrance to the resident's room instead of the required contact isolation precautions. Staff, including an LVN and a CNA, were unaware of the correct precautions and followed the posted EBP sign rather than the physician's order and care plan. Further, the CNA entered the resident's room carrying bed linens, set them on the resident's bed, and failed to don gloves before entering, only putting on a gown after entry. The CNA confirmed she should have donned both gown and gloves before entering and was unaware of the specific contact isolation order. The DON verified that the facility did not implement the required contact precautions as outlined in the resident's care plan.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing assistant (RNA) services as ordered by physicians for multiple residents with impaired range of motion (ROM) and mobility. Physician orders and care plans for several residents required specific RNA interventions, such as passive or active-assisted ROM exercises, application of orthotic devices, and ambulation assistance, to be performed five times a week or as tolerated. Documentation revealed that these services were not consistently provided according to the orders, with several days missed for each resident. There was no documented evidence explaining the missed RNA services or any clinical justification for not following the prescribed interventions. For example, one resident with impaired ROM in all extremities and a care plan to maintain current ROM functions did not receive the required frequency of PROM exercises and orthotic device applications. Another resident with bilateral hand contractures and impaired ROM was not provided with hand rolls and PROM exercises as ordered. Additional residents with limited mobility, functional quadriplegia, or other impairments also missed multiple RNA sessions, despite clear physician orders and care plan interventions specifying the frequency and type of restorative care needed. Interviews with staff, including RNAs, RNs, and the DON, confirmed that RNA services were not provided as ordered due to staffing shortages and the reassignment of RNAs to CNA duties. Staff acknowledged the missed services and verified that documentation did not reflect the required frequency of RNA interventions. The facility's policy on restorative nursing services required individualized, resident-centered care as outlined in each resident's plan, but this was not followed for the residents reviewed.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor and address significant weight loss for one resident who experienced a 28-pound decrease within two days of admission, followed by an additional 3-pound loss over the next three days. Despite facility policy requiring weights to be retaken and verified when a significant change is noted, and immediate notification of the dietitian and physician, there was no documented evidence that the resident's weight loss was reassessed, communicated to the physician, or that any follow-up occurred. The resident's medical record did not contain an assessment or monitoring for the significant weight loss, nor was there documentation explaining the reason for the drastic change. The care plan for the resident identified a nutritional problem and risk for weight fluctuation due to dialysis and refusal of treatment, with a goal to prevent significant weight loss or gain. However, the care plan did not specify what constituted significant weight change for this resident. During interviews, the DON acknowledged the lack of documentation and monitoring following the weight loss event. The resident was observed to have a good appetite and food preferences were met, but reported a lack of appetite at meal times.
Deficiencies in GT Medication Administration, Diet Orders, and Positioning
Penalty
Summary
The facility failed to ensure appropriate care and services for residents with gastrostomy tubes (GT), as evidenced by multiple deficiencies in medication administration, diet orders, and positioning during enteral feeding. For one resident with a GT and a diagnosis of dysphagia, the physician's orders for medication administration specified the oral route, despite the resident being unable to take anything by mouth. Licensed nurses administered and documented medications as given orally, even though the resident required all medications via GT. Staff interviews confirmed that the medication orders did not accurately reflect the resident's needs and that the route should have been updated to GT. Additionally, three residents with GTs did not have physician-ordered diets in their medical records. Staff, including LVNs, RNs, and the DON, acknowledged that all residents, including those with GTs, are required to have a diet order upon admission. The absence of a diet order was verified through medical record review and staff interviews, with staff stating that the expectation is to contact the physician to obtain the appropriate order or a swallow study if one is missing. Observations revealed that two residents receiving enteral feedings via GT were not positioned with the head of bed (HOB) elevated to at least 30 degrees, as required by physician orders and facility policy. Both residents were observed with the HOB elevated less than 30 degrees during feedings. Staff interviews confirmed that the HOB should have been elevated to prevent complications such as aspiration. The DON and other nursing leaders acknowledged these findings during interviews.
Failure to Label and Timely Discontinue Peripheral IV Access
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a peripheral IV (PIV) access. Observation revealed that the resident's PIV site was not labeled as required by the facility's policy, which specifies that the dressing should include the date and time of placement, staff initials, gauge size, and catheter length. Additionally, the PIV was not discontinued after IV therapy was completed, despite the facility's policy stating that peripheral catheters should be removed if not used for 24 hours or if therapy is discontinued. The resident's IV antibiotics were discontinued, and oral antibiotics were started, yet the PIV remained in place and unlabeled. Interviews with nursing staff and the DON confirmed that there were no active physician orders for IV medication or maintenance, and that the PIV should have been discontinued after the completion of IV antibiotics. The staff acknowledged that the PIV had not been used since the previous week and that it should have been removed to prevent potential complications. The failure to follow policy regarding labeling and timely removal of the PIV was verified through observation, interview, and medical record review.
Failure to Rotate Enoxaparin Injection Sites as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident who was prescribed enoxaparin sodium injections for DVT prophylaxis. According to the physician's order, the injection sites were to be rotated, and the facility's policy and procedure for subcutaneous injections required licensed nurses to verify the order and rotate injection sites to ensure proper administration. Medical record review revealed that the injection sites for the resident were not rotated as required, with multiple consecutive injections administered to the same area of the abdomen over several days. Interviews with nursing staff, including an LVN and an RN, confirmed that they were aware of the need to rotate injection sites and that the physician's order included this instruction. Both staff members reviewed the medication administration records and verified that the injection sites had not been rotated. The DON also confirmed that the facility's policy was not followed in this instance. The failure to rotate injection sites was directly observed in the documentation and acknowledged by the staff involved.
Pharmacist Failed to Identify Missing Dose in Medication Order
Penalty
Summary
A deficiency occurred when a licensed pharmacist failed to identify and report a medication irregularity for one resident during the required monthly drug regimen review. The resident had a physician's order for docusate sodium, but the order did not specify the dose to be administered. Despite this omission, the medication was administered as one 100 mg tablet twice daily via gastrostomy tube (GT), based on the facility's available stock, without clarification from the physician. The medication administration record (MAR) and the physician's order both lacked the specified dose, and the resident had been receiving the medication in this manner since the order was written. During interviews, the LVN confirmed that the dose was assumed due to the available tablet strength and acknowledged that clarification should have been sought. The consultant pharmacist, upon review, stated that each medication order should include a specified dose and acknowledged that the missing dose was not identified during the monthly medication regimen review. The facility's policy required the pharmacist to identify such irregularities, but this was not done, resulting in the deficiency.
Medication Error Rate Exceeds Acceptable Threshold Due to Dose Verification and Administration Failures
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5%, as evidenced by a calculated error rate of 14.29% during surveyor observation. Two of four licensed nurses were observed making medication administration errors involving two residents. One nurse administered docusate sodium to a resident without verifying the specific dose, as the physician's order and the Medication Administration Record (MAR) both lacked a specified dosage. The nurse assumed the correct dose was 100 mg, based on available stock, and administered it without clarification from the physician, despite acknowledging that other dosages exist and that clarification should have been sought. Another nurse failed to ensure the full dosages of three out of nine prescribed medications were administered to a different resident. After administering the medications via gastrostomy tube (GT), inspection of the medication cups revealed residue of aspirin, vitamin D3, and multivitamins with minerals, indicating incomplete administration. The nurse verified the presence of residue in the cups after administration, confirming that the resident did not receive the full prescribed doses of these medications. The facility's policies and procedures require verification of medication orders, including dose, prior to administration, and proper preparation and administration of medications through enteral tubes. Both nurses failed to adhere to these protocols, resulting in medication errors that were directly observed and confirmed through interviews and record reviews. The Director of Nursing acknowledged these findings and confirmed that medication doses must be specified and verified before administration.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals as required by professional standards and its own policies. During an observation, a resident with a below-the-knee amputation was found with a medicine cup containing an unidentified dark liquid on her nightstand; the resident was unaware of its contents. The DON later identified the liquid as Betadine, a prescribed antiseptic solution, and acknowledged it should not have been kept at the bedside. Additionally, expired medications were found in two separate medication carts during inspections with nursing staff, including a bottle of instant hand sanitizer and a bottle of Curad iodoform packing strip, both past their expiration dates. Staff verified the presence of these expired items. Further, the facility did not ensure that medication carts were securely locked when unattended. An LVN was observed leaving a medication cart unlocked while administering medications in a resident's room, which was confirmed by the staff member. The DON acknowledged these findings during an interview. These actions and inactions demonstrate a failure to adhere to the facility's policies and regulatory requirements for safe and secure medication storage.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors identified multiple failures in food safety and sanitation practices within the facility's kitchen. During an initial tour with the Dietary Service Supervisor, it was observed that the can opener blade's coating was removed or stripped, two frying pans had grayish black residue, and a strainer had white residue. These items were stored among other clean kitchen equipment. The Dietary Service Supervisor confirmed the condition of these items during the inspection. Further observations included an opened box of gloves placed on top of clean plates in the dishwashing area, as verified by the Kitchen Dishwasher, and food residue scattered on the roof surface of a microwave used by residents, as confirmed by an LVN. The Director of Nursing (DON) later verified all these findings. These deficiencies were noted to affect 39 residents who consumed food prepared in the kitchen, as documented in the facility's matrix.
Improper Trash and Sharps Disposal Leading to Sanitation Deficiency
Penalty
Summary
The facility failed to dispose and store trash in a sanitary manner, as evidenced by multiple observations of overflowing dumpster bins and improper disposal of sharps containers. Specifically, two of five dumpster bins were found overflowing with trash, preventing the lids from fully closing, and trash such as used gloves, masks, and other debris was scattered on the ground near the bins. Additionally, seven sharps disposal containers were observed placed on top of biohazard waste bins in the Infectious Waste Matter Room, rather than being properly disposed of inside the bins. The Central Supply Supervisor confirmed that these practices did not meet facility standards for pest prevention and disease control. Further observations revealed that non-trash items, including wheelchair wheels, a wrecked filing cabinet, and a pot, were improperly stored beside the facility's generator machine instead of being disposed of in the appropriate dumpster. The Central Supply Supervisor acknowledged that these items should not have been left in that area. The DON verified all of the above findings during an interview. These deficiencies were identified through direct observation and staff interviews, and were found to be inconsistent with the US Food Code 2013 requirements for refuse storage and disposal.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, a physician's order for an NPO (nothing by mouth) diet dated 1/29/25 was not discontinued in the medical record, despite a subsequent order on 5/13/25 allowing a NAS (no added salt) diet with pureed texture and regular/thin consistency for oral gratification. Documentation showed the resident was offered oral gratification since 5/13/25, but the outdated NPO order remained active, which was confirmed by both a registered nurse and the Director of Nursing during interviews and record reviews. For another resident with a left upper arm AV shunt for hemodialysis, the facility's policy prohibited taking blood pressure on the access arm. However, medical record review revealed that blood pressure readings were repeatedly documented as being taken from the left arm over several days. The resident, who was cognitively intact, confirmed that the left arm was used for hemodialysis and that staff were not permitted to take blood pressure on that arm. Multiple licensed nurses verified that blood pressure readings had been obtained and documented from the left upper extremity, and the Director of Nursing acknowledged that this should not have occurred.
Infection Control Program Deficiencies and Lapses in Isolation and Hygiene Practices
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, resulting in multiple lapses in infection control practices for both sampled and nonsampled residents. For one resident with a physician's order for contact isolation due to Clostridium Difficile colitis, the facility did not provide a private room, did not use dedicated medical equipment, and did not post appropriate signage indicating the required isolation precautions. Staff members, including an LVN and a CNA, did not follow proper PPE protocols or hand hygiene procedures, and the Infection Preventionist (IP) provided incomplete information to the resident's physician regarding the resident's ongoing symptoms, failing to review the medical record for continued episodes of diarrhea before discontinuing isolation. Additional deficiencies were observed in the handling of enhanced barrier precautions (EBP) for other residents. Signage indicating the type of isolation precautions was missing outside rooms where residents were on EBP for multidrug-resistant organisms, despite the presence of isolation carts and PPE instructions. Staff were observed transporting soiled linens against their clean scrubs without wearing gowns, contrary to facility policy, and failing to perform hand hygiene during and after medication administration, even after removing gloves or touching equipment in the vicinity of other residents. The facility also lacked a comprehensive, facility-specific water management program as required by CMS and its own policies. The water management binder did not contain the necessary flowcharts, testing protocols, or documentation of control measures and corrective actions. Staff interviews confirmed the absence of these required elements, and the facility was unable to provide evidence of a water management program that met regulatory and policy standards.
Failure to Offer Recommended Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to offer pneumococcal conjugate vaccines (PCV 20, PCV 21, or PCV 15) to a resident who had previously received only the PPSV23 vaccine, as required by current CDC recommendations. The facility's policy stated that all residents would be assessed for pneumococcal vaccine eligibility upon admission and offered the vaccine series within thirty days if indicated, with administration to follow CDC guidelines. However, review of the resident's medical record and the California Immunization Registry (CAIR2) confirmed that the resident had only received PPSV23 and was not offered any of the recommended PCV vaccines after that dose. During an interview, the Infection Preventionist (IP) stated that vaccination status was reviewed upon admission and annually, relying on CAIR2 data and family input. The IP believed, based on pharmacy consultant advice, that a new vaccine was not needed until five years after the PPSV23 dose, which was inconsistent with updated CDC guidelines. The IP confirmed that the resident's pneumococcal vaccination status was not up to date according to current recommendations, and there was no documentation showing the resident was offered the appropriate PCV vaccine.
Failure to Maintain Medication Refrigerator and Glucometer Quality Control
Penalty
Summary
Surveyors observed that the facility failed to maintain essential equipment in a clean and safe operating condition. Specifically, the medication refrigerator in Medication Room A, used to store residents' medications, was found to have thick ice buildup in the frozen storage area, which did not have a separate door. Multiple medications for several residents were stored in this refrigerator. The RN confirmed that the refrigerator was only being defrosted monthly and acknowledged that more frequent defrosting was needed. The DON was informed and acknowledged these findings. Additionally, the facility failed to ensure that quality control checks were consistently performed for the glucometer in Medication Cart C. During inspection and document review, it was found that there was no documentation to show that glucometer calibration was performed on two specific dates, despite staff stating that calibration was supposed to occur nightly and be recorded. The DON was also informed and acknowledged this deficiency.
Failure to Maintain Bed System Safety and Compliance with FDA Guidelines
Penalty
Summary
The facility failed to ensure that bed systems, including bed frames, mattresses, and bed rails, were regularly inspected and maintained in accordance with FDA guidelines and the facility's own policies and procedures. For three residents who used bilateral side rails, measurements of gaps in the bed systems were found to exceed the maximum allowable dimensions for several entrapment zones, specifically Zones 1, 2, and 4. These measurements were verified by the Central Supply Supervisor and were not within the 4.75-inch limit established by the FDA and referenced in the facility's Bed Safety policy. There was no documentation to show that corrective actions were taken to address these out-of-range measurements. For one resident, the Bed Safety Checklist showed Zone 1 and Zone 2 gaps measured 10.5 inches and 10 inches, respectively, both exceeding the recommended maximum. Another resident's checklist showed Zone 1 at 10.5 inches, Zone 2 at 10 inches, and Zone 4 at 5.5 inches, all above the allowable limits. A third resident had a Zone 2 gap of 9.5 inches, also exceeding the standard. In each case, the Central Supply Supervisor confirmed the measurements and acknowledged that there was no evidence of follow-up or correction. Additionally, interviews revealed that there was no regular schedule or log for bed maintenance, and the Maintenance Director, who was responsible for these tasks, was unavailable for interview. The residents involved had orders and care plans in place for the use of side rails as enablers to promote independence, bed mobility, or for seizure precautions. Informed consent was documented where appropriate, and residents or their representatives were aware of the risks and benefits of side rail use. However, despite these measures, the facility did not ensure that the physical safety standards for bed systems were met, as required by both internal policy and federal guidance. Facility leadership, including the Assistant Administrator and DON, verified and acknowledged the findings during the survey.
Inaccurate and Incomplete MDS Discharge Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two of three residents whose closed records were reviewed. For one resident, the physician's order and progress notes indicated discharge to a board and care facility under palliative and hospice care, but the MDS assessment incorrectly documented the discharge as a transfer to a short-term general hospital. The MDS Coordinator confirmed this discrepancy during an interview and record review. For another resident, the physician's order showed discharge to home under hospice care, and progress notes confirmed the resident was discharged home. However, the MDS assessment for this resident was found to be incomplete, with the discharge section left blank and not completed. The MDS Coordinator acknowledged that the discharge assessment should have been completed. The Director of Nursing (DON) verified both findings during interviews.
Failure to Administer Medications Per Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not administer metoprolol tartrate and hydralazine according to the physician's orders for a resident with hypertension. The physician's orders specified that metoprolol should be held if the systolic blood pressure (SBP) was less than 110 mmHg or the heart rate (HR) was less than 60 beats per minute, and hydralazine should be held if the SBP was less than 110 mmHg. However, the resident received metoprolol when their blood pressure was 105/54 mmHg and when their heart rate was 55 beats per minute. Additionally, hydralazine was administered when the resident's blood pressure was 106/55 mmHg. Interviews with the LVN and the DON confirmed that the medications were not administered per the physician's orders and parameters. The LVN acknowledged that administering blood pressure medications outside of the ordered parameters could lead to further lowering of the resident's blood pressure and/or heart rate, potentially resulting in negative outcomes. The DON stated that nurses were expected to read and follow the physician's orders when administering medications. The AIT and DON acknowledged the findings during the interview.
Failure to Honor Resident's Request for CNA Assignment
Penalty
Summary
The facility failed to consistently honor a resident's request not to have a specific CNA assigned to her for ADL care needs, which compromised the resident's right to dignity and respect. The facility's policy on Resident's Rights, revised in December 2016, guarantees residents the right to a dignified existence and to be treated with respect. Despite this, the resident had previously complained about the CNA and requested not to have her assigned, yet the CNA was assigned to the resident during a night shift. During an interview, the resident confirmed that she had complained about the CNA and had not been cared for by her since the complaint, except for an incident on a night shift when the CNA was assigned to her and changed her incontinence brief. The resident had informed the CNA not to touch her, but the CNA insisted on checking the incontinence brief. The resident eventually gave permission for the CNA to change the brief. The facility's Assignment Binder had clear instructions not to assign the resident to the CNA, indicating a failure to adhere to the resident's request and facility policy.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to provide the necessary care and services to ensure a resident was free from accidents when it did not follow the care plan requiring two-person assistance with bed mobility. The resident, who was dependent on a respirator and had no capacity to understand or make decisions, fell to the floor while being changed and turned in bed by one CNA. This resulted in the resident sustaining a head injury with profuse bleeding and a fracture of the first cervical vertebra, necessitating transfer to an acute care hospital. The facility's policies and procedures required appropriate support and assistance with activities of daily living (ADL) and a resident-centered fall prevention plan. The resident's care plan specifically indicated the need for two-person assistance for bed mobility due to the resident's ADL deficits and risk of falling. However, the CNA, who was working with the resident for the first time and was not informed of the two-person assistance requirement, attempted to turn the resident alone, leading to the fall. Interviews with facility staff, including the CNA, LVN, DON, and others, confirmed that the resident required two-person assistance for bed mobility. The CNA admitted to not asking for assistance and attempting to change the resident alone. The DON and other staff verified that the care plan was not followed, and the CNA should have requested help. The incident highlights a failure in communication and adherence to the care plan, resulting in significant harm to the resident.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to ensure the proper storage, labeling, and disposal of medications in multiple medication carts and rooms. During an inspection of Medication Cart A, expired medications and blood glucose strip bottles with unreadable lot numbers and expiration dates were found. Additionally, medications were improperly stored with antiseptics and supplements. Similar issues were observed in Medication Cart C, where expired luer lock caps were found, and in Medication Cart B, where odor eliminator spray was stored with oral rinse medications. Medication Cart D contained expired sore throat spray and improperly stored nasal sprays with tablets and inhalation solutions with oral suspensions. Medication Cart F had expired COVID-19 test kits, and Medication Cart G had medications stored with personal items and disinfecting wipes. Medication Cart H contained loose pills and improperly stored medications, while Medication Cart E had similar storage issues with transdermal patches and injections mixed together. Medication room [ROOM NUMBER] had expired lactulose solution and improperly stored inhalation solutions with other medications. Additionally, the Facility Medication Destruction Forms were missing required signatures for several dates, and unauthorized personnel were observed in the medication room without supervision. The facility's policies and procedures for medication labeling and storage, as well as discarding and destroying medications, were not followed. Medications were found stored in an unsafe manner, with oral medications mixed with external use medications, and expired medications were not disposed of properly. The facility's policy required medications to be stored in locked compartments under proper conditions, with clear labeling and separation of different types of medications. However, multiple instances of non-compliance were observed, including the presence of expired medications, improper storage of antiseptics with medications, and the mixing of oral and external use medications. The Facility Medication Destruction Forms also lacked the necessary signatures from licensed nurses, indicating a failure to follow the proper procedures for medication destruction. Unauthorized personnel were observed in the medication room without supervision, which is against the facility's policy that only licensed nurses should have access to medication rooms. This lapse in security could potentially lead to unauthorized access to medications. The Director of Nursing (DON) verified the findings and acknowledged the deficiencies, including the missing signatures on the medication destruction forms and the presence of unauthorized personnel in the medication room. The facility's failure to adhere to its policies and procedures for medication storage, labeling, and disposal poses a risk to the safety and well-being of the residents.
Failure to Follow Prescribed Menus and Portion Sizes
Penalty
Summary
The facility failed to ensure that 36 of 94 residents who received food from the kitchen were provided with the proper diets and portion sizes as per the facility's menus. Specifically, the facility did not follow the menu for the BBQ Chicken puree recipe, did not serve the correct portion sizes for ground BBQ chicken and potato salad, and did not provide homemade BBQ sauce for residents on CCHO diets as required. These failures were observed during food preparation and meal service, where deviations from the prescribed recipes and portion sizes were noted. For instance, Cook 1 did not measure ingredients accurately while preparing pureed BBQ chicken and used incorrect scoop sizes for serving mechanical soft texture BBQ chicken and potato salad. Additionally, Cook 1 used bottled BBQ sauce instead of homemade BBQ sauce for residents on CCHO diets, contrary to the menu specifications. The deficiencies were confirmed through interviews with the Registered Dietitian (RD) and observations during meal preparation and service. The RD verified that all recipes and menus should be followed precisely. The Director of Dietary Services (DSS), Director of Nursing (DON), and Administrator were informed of these findings and acknowledged the discrepancies. The facility's failure to adhere to the prescribed menus and portion sizes had the potential to compromise the nutritional needs of the residents, which could lead to medical complications.
Failure to Provide Properly Prepared Mechanically Altered Diets
Penalty
Summary
The facility failed to ensure that residents on mechanically altered diets received food in a form that met their individual needs. Specifically, the pureed bread was not prepared according to the recipe, resulting in a sticky, gummy texture with pieces of thickened bread throughout the product. This was confirmed by the Dietary Services Supervisor (DSS), Registered Dietitian (RD), and Speech Language Pathologist (SLP) during observations and interviews. Additionally, one resident on a mechanical soft NAS (No Added Salt) CCHO (Consistent Carbohydrate) diet received regular textured meat instead of the prescribed ground BBQ chicken, and another resident on a mechanical soft finely chopped meat diet received a pureed diet instead of finely chopped meat. The facility's documentation and menu did not include a specific diet titled mechanical soft finely chopped, leading to confusion and incorrect meal preparation. These deficiencies were observed during a lunch meal tray line observation and confirmed through interviews with the DSS, RD, and SLP. The SLP emphasized the importance of verifying terminology used to distinguish between different mechanically altered diets. The failure to follow the prescribed diets posed a risk for complications such as choking for nine residents on mechanically altered diets, including seven residents on a pureed diet and two residents on mechanical soft diets.
Failure to Complete Entrapment Assessments and Measurements
Penalty
Summary
The facility failed to ensure that residents' entrapment assessments were complete and that measurements were recorded during bed inspections for six residents. The facility's policy required assessments to determine the risk of entrapment and to measure the space between the mattress and side rails. However, the assessments for the entrapment zones were either incomplete or not documented at all. This failure was observed in multiple instances, including residents who had physician orders for side rails for security or mobility purposes but lacked proper entrapment risk assessments and measurements. For example, Resident 351 had a high-risk score for entrapment, but the assessment did not include measurements for each entrapment zone. The Maintenance Director confirmed that he did not measure the bed rails or inspect for entrapment risks. Similarly, Resident 16 had side rails for mobility purposes, but the entrapment risk assessment was incomplete. The Maintenance Director and the Director of Nursing (DON) acknowledged that the facility had inconsistent assessments and lacked documentation for entrapment risks. Other residents, such as Residents 18, 33, 61, and 62, were also observed with side rails elevated, but their entrapment assessments were either incomplete or not conducted. The Maintenance Director admitted that he only checked the side rails when staff reported problems and did not perform measurements before installation. The DON confirmed that the facility's policy required routine inspections to identify risks, including potential entrapment, but these were not consistently carried out, leading to the deficiencies noted in the report.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide two residents with the required Notice of Medicare Non-coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055. Resident 901, who was admitted and later discharged home, did not receive the NOMNC. Similarly, Resident 902, who was readmitted and later discharged home, did not receive either the NOMNC or the SNF ABN Form. This failure was identified through medical record reviews and interviews with the facility's Administrator, who confirmed the absence of these documents in the residents' records. The facility's policy, dated April 2018, mandates that a completed copy of the NOMNC be given to beneficiaries at least two days before the termination of services. However, the Administrator was unable to provide documentation showing that these notices were given to Residents 901 and 902. The Administrator attributed the oversight to the previous Social Services Director, who did not keep copies of the forms. This lapse potentially prevented the residents from making informed decisions regarding their Medicare services.
Failure to Implement Restraint-Free Periods
Penalty
Summary
The facility failed to implement the restraint-free periods for two residents, as required by their care plans and physician orders. Resident 39 had a physician order to apply bilateral hand mittens and release them every two hours for at least 10 minutes. However, observations and interviews revealed that the mittens were not consistently released for the required duration, and there was no documentation of the release periods or assessments of the resident's skin and mobility. Similarly, Resident 46 had orders to apply bilateral hand mittens and release them every two hours for at least 10 minutes. Observations and interviews confirmed that the mittens were not released for the required duration, and there was no documentation of the release periods or assessments of the resident's circulation and mobility. The facility's policy on the use of restraints mandates that residents in restraints be observed every thirty minutes and given opportunities for motion and exercise for at least 10 minutes every two hours. Despite this policy, the facility did not adhere to these guidelines for Residents 39 and 46, as evidenced by the lack of documentation and the staff's admissions during interviews. These failures posed a risk to the residents' independence and psychosocial well-being, as the required restraint-free periods were not consistently implemented or documented.
Failure to Develop Comprehensive Care Plan for Food Storage
Penalty
Summary
The facility failed to ensure a comprehensive, resident-centered care plan was developed for a resident (Resident 40) who stored perishable and nonperishable food items in their room. During an observation and interview, it was noted that Resident 40 had various food items, including chips, dehydrated soup, pastries, instant hot chocolate, canned goods, fresh potatoes, and tomatoes, stored on shelves in their room. Additionally, Resident 40 had a small refrigerator containing pudding, potato salad, butter, and cheese. The resident stated it was their right to store these food items in their room. However, this practice was not compliant with the facility's policies and procedures regarding the storage of food from the outside, and there was no care plan addressing this issue for Resident 40. An interview with LVN 11 confirmed that it was the nursing staff's responsibility to create and revise a baseline care plan for each resident as needed, quarterly, and annually. LVN 11 acknowledged that Resident 40 was not compliant with the facility's policies and procedures regarding food storage and that this should have been included in the resident's care plan. The absence of a care plan addressing the storage of food from the outside for Resident 40 indicates a failure to provide appropriate, consistent, and individualized care for the resident.
Improper Medication Administration by LVN
Penalty
Summary
The facility failed to ensure the services provided met professional standards of care when LVN 7 improperly administered medication to Resident 44. During a medication administration observation, LVN 7 was seen administering Flonase Allergy nasal spray to Resident 44 without following the facility's policy and procedure (P&P) for nasal inhalers, sprays, and pumps. Specifically, LVN 7 did not instruct the resident to press a finger against the side of the nose to close one nostril, keep his mouth closed, and sniff in through the open nostril while the nasal spray was squeezed. Additionally, LVN 7 did not instruct Resident 44 to hold his breath for a few seconds and then breathe out through the mouth after squeezing the nasal spray. In an interview, LVN 7 confirmed that he did not provide Resident 44 with any directions during the administration of the nasal spray, stating that the resident already knew how the medication worked. The Director of Nursing (DON) was informed of the findings and acknowledged the deficiency. This failure had the potential to negatively impact the resident's health due to malabsorption and reduction in the effectiveness of the medication.
Failure to Apply Heel Protector Boots as Ordered
Penalty
Summary
The facility failed to ensure the heel protector boots were applied to Resident 33's bilateral lower extremities (BLEs) as per the physician's order. Resident 33 was admitted to the facility and had a physician's order dated 3/3/24 to apply heel protector boots to the BLEs every shift for wound management and prevention while in bed. On 4/17/24, during an observation and interview, it was verified by both a CNA and an LVN that Resident 33 was not wearing the heel protectors while in bed. This failure had the potential to affect the resident's well-being.
Failure to Provide Ordered RNA Services
Penalty
Summary
The facility failed to provide the Restorative Nursing Assistant (RNA) services as ordered by the physician for Resident 87, which had the potential to cause a decline in the resident's range of motion and mobility. The physician's orders included passive range of motion (PROM) exercises for both upper and lower extremities, as well as the application of elbow and knee extension splints, to be performed five times a week or as tolerated. However, a review of Resident 87's Restorative Record for February and April 2024 revealed missing documentation for the RNA services on specific dates, indicating that the services were not provided as ordered on 2/10, 2/24, 4/7, and 4/13/24. RNA 5 confirmed that he was not working on those days, and the Director of Nursing (DON) verified the findings, stating that missed exercises on a Saturday could be made up on the following Thursday. The facility's policy and procedure (P&P) for charting and documentation, dated July 2017, requires that treatments or services performed be documented in the resident's medical record. The failure to document and provide the ordered RNA services for Resident 87 was identified through interviews, medical record reviews, and a review of the facility's P&P. This deficiency highlights a lapse in the facility's adherence to physician orders and proper documentation practices, which are essential for maintaining and improving residents' range of motion and mobility.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident identified as being at high risk for falls (Resident 23) remained free from accident hazards. Despite a physician's order dated 8/28/23 to implement bilateral floor mats to prevent injury in the event of a fall, these mats were not in place during observations on 4/15/24 and 4/16/24. Resident 23, who was wearing a yellow wristband indicating fall risk, was observed lying in bed without the required floor mats. The resident's care plan, which included the intervention to implement floor mats, was not followed, placing the resident at risk for serious injury in the event of a fall. Interviews with LVN 3 confirmed that Resident 23 was a fall risk and that the required bilateral floor mats were not in place as per the physician's order and care plan. LVN 3 acknowledged the potential risk for injury due to the absence of the mats. The deficiency was verified through medical record reviews and direct observations, and the Director of Nursing (DON) was informed and acknowledged the findings on 4/17/24.
Failure to Maintain IV Accesses and Develop Care Plans for PICC Lines
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the IV accesses for two residents, specifically regarding the use of PICC lines. For both residents, the facility did not complete and document the PICC line external catheter and arm circumference measurements upon admission. Additionally, there were no physician's orders for the care and maintenance of the PICC lines, and no care plans were developed to address the use of the PICC lines. These deficiencies were confirmed through observations, interviews, and medical record reviews conducted by the surveyors. Resident 53 was observed with a PICC line on the right upper arm, and Resident 67 was observed with a PICC line on the left upper arm. Both residents' medical records lacked documentation of the necessary measurements and physician's orders for PICC line care. Interviews with LVN 13, RN 1, RN 6, the MDS Coordinator, and the DON confirmed these findings. The MDS Coordinator and the DON acknowledged that there should have been specific care plans formulated for the use of the PICC lines for both residents.
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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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