Huntington Drive Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Arcadia, California.
- Location
- 400 W. Huntinton Dr., Arcadia, California 91007
- CMS Provider Number
- 055376
- Inspections on file
- 84
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Huntington Drive Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, benign prostatic hyperplasia, and an indwelling Foley catheter had a care plan requiring catheter care and catheter/bag changes, but chart review over several months showed no physician order for Foley care and no documentation that such care was provided. The resident was cognitively impaired and dependent for ADLs, including toileting and hygiene. Nursing staff, including treatment nurses and an RN, acknowledged that Foley care (genital cleansing with soap and water, monitoring for infection, ensuring proper catheter positioning and securement, and keeping the drainage bag off the floor) should have been provided and documented for all residents with Foley catheters. Staff also reported there was no facility policy specific to Foley catheter care, despite a general policy requiring comprehensive person-centered care plans with measurable objectives.
A resident with a left abdominal colostomy, partial intestinal obstruction, and CKD required assistance with hygiene and toileting and had physician orders for colostomy care and as-needed emptying of the colostomy bag. Over a multi-week period, the TAR and electronic record contained no entries showing that colostomy care or colostomy bag changes were provided, despite a care plan directing appliance changes per orders. Nursing staff acknowledged that, per facility protocol and the colostomy/ileostomy care policy, such care should include assessment of the stoma and surrounding skin, cleaning, and emptying or changing the bag, and must be documented with date, time, staff identification, skin findings, resident tolerance, and any refusals, but this documentation was absent.
The facility failed to address repeated grievances from two cognitively intact residents regarding a roommate who refused to allow use of a shared restroom or permit CNAs to obtain water there for care of roommates. One resident reported being blocked from using the in-room restroom and call light and stated that complaints to the ADM and at resident council meetings were not resolved. Another resident reported that CNAs had to use her restroom to get water to bathe the controlling resident’s roommate and that leadership was aware through council meetings. Multiple CNAs and the SSD confirmed that previous roommates complained, were redirected to other residents’ restrooms, and often requested room changes, while the DON and an RN acknowledged that roommates had the right to use the shared restroom and that follow-up and closure to the grievances had not occurred, contrary to the facility’s resident rights policy.
A resident with COPD, a history of falls, and identified fall risk had three oxygen tanks stored in the restroom and two additional tanks just outside the restroom near the bed. Staff, including an LVN, RN, and the DON, acknowledged that multiple oxygen tanks in the room and restroom were a safety, trip, and fire hazard and that only one tank for active use should be in the room, with others stored in the designated oxygen storage area. Facility policies on fire safety and resident safety explicitly prohibited storing oxygen cylinders in resident rooms or living areas and required maintaining an environment free from accident hazards, but these policies were not followed in this case.
A resident with severe cognitive impairment, gait abnormalities, and need for assistance with bed mobility and transfers had physician-ordered bilateral 1/3 bed rails as an enabler for mobility and positioning. During observation, the resident was found in bed with both rails raised, and an LVN discovered the rails were stuck and could not be lowered. A Maintenance Assistant removed and reinstalled the rails but was still unable to lower one side and acknowledged that this type of bed’s rails were not working properly. A CNA stated the rails should function because staff use them during care, and the DON affirmed beds should be in good working order. These findings showed the bed rails were malfunctioning and not maintained per facility policies requiring equipment to be safe, operable, and repaired or replaced when worn or defective.
Two residents were not treated with dignity and did not have their preferences accommodated when one resident was left sitting in a wheelchair for an extended period after a room transfer because clothes and personal belongings were left piled on the bed, preventing use of the bed, and a functional TV remote was never provided. Staff interviews confirmed that CNAs were expected to put belongings away during room moves and that the remote available was incompatible with the resident’s TV. Another resident, who valued keeping up with the news, reported that key news channels on the TV were blurred or nonfunctional, which was confirmed by the maintenance assistant. The DON acknowledged that TV remotes and channels should work so residents can watch their preferred programs.
A resident with bilateral hip osteoarthritis and a right artificial knee joint, who had intact cognition and required assistance with ADLs, had a physician’s order for RNA ambulation services three times per week using a front-wheeled walker and gait belt. Review of RNA logs and documentation, along with staff interviews, showed that ordered RNA ambulation sessions were missed on multiple days and that the resident received fewer sessions than ordered. The resident reported that RNA staff did not come as scheduled, and the DSD confirmed that undocumented RNA services were not performed. The DON stated that RNA services are important to maintain mobility and acknowledged that the resident did not have an RNA care plan, despite facility policy requiring restorative goals and interventions to be outlined in the plan of care.
Two residents with respiratory conditions did not receive oxygen therapy as ordered, with one not wearing the nasal cannula and receiving an incorrect oxygen flow rate, and another experiencing low oxygen saturation levels without physician notification. Facility staff failed to follow physician orders and facility policy regarding oxygen administration and documentation.
The facility did not maintain a safe and sanitary environment by failing to address water leaks in a hallway and a resident's room. Water damage was observed, with water leaking into bins and towels used to absorb excess water. A resident with significant medical needs reported water leaking onto personal items, and staff confirmed the presence of water damage. Maintenance staff were unaware of the issue due to a lack of proper reporting and communication, and required maintenance logs and electronic reports were not completed.
A resident received a Foley catheter without documentation of the medical indication, time of insertion, or required monitoring of intake and output, contrary to facility policy. Nursing staff and the DON confirmed that the order lacked an indication and that documentation and care planning were incomplete at the time of catheter insertion.
A resident with a history of hemiplegia and hemiparesis experienced dizziness and vomiting, which was reported to nursing staff but not documented in the medical record. Licensed staff and the DON confirmed that such symptoms should have been recorded according to the care plan and facility policy, resulting in an incomplete and inaccurate medical record.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident prescribed Ambien for insomnia did not have their hours of sleep properly documented, as required by physician orders. Instead of recording the specific number of hours slept, staff only marked check boxes on the MAR, making it unclear whether the medication was effective. Interviews with the resident, an LVN, and the ADON confirmed that this monitoring was incomplete and did not meet facility policy for psychotropic medication management.
A resident with a history of cerebral infarction and dementia reported to the DSD that she hit her head on a grab bar in the bathroom. The DSD did not notify the physician, document an assessment, or initiate a Change of Condition, and there was no evidence of monitoring or treatment in the medical record, contrary to facility policy.
A resident with a history of falls, bilateral leg weakness, and total dependence for bed mobility, who was using a low air loss mattress, experienced a fall during incontinent care when only one CNA was present. The care plan did not specify the required staff assistance or interventions needed to prevent falls during such care, despite facility policy and staff knowledge that two staff should be present for residents on a LALM.
A resident with major depressive disorder and hemiplegia was discouraged from voicing grievances after a CNA told her that continued complaints would result in no one wanting to work with her. This statement violated the facility's policy on resident rights, which ensures grievances can be voiced without fear of discrimination or reprisal. The Director of Staff Development confirmed the CNA's actions were inappropriate and not in line with the facility's policy.
The facility failed to maintain a homelike environment, as 10 resident rooms were found with chipped and peeling paint, contrary to the facility's policy. Observations confirmed the presence of unpainted patched areas, and interviews with staff, including the Maintenance Supervisor and DON, acknowledged the need for repainting. The ADM was aware of the issue, which posed a risk for an unsafe and unclean environment.
The facility failed to follow proper food handling practices, resulting in several opened and expired food items being improperly labeled or not discarded. During a kitchen tour, the Dietary Supervisor identified items like seasoning salt, ground ginger, and pasta that lacked proper labeling, and expired items like browning sauce and food coloring were found in the kitchen. The facility's policy requires labeling with delivery or use-by dates and discarding expired items, which was not adhered to, potentially exposing residents to foodborne illnesses.
The facility failed to adhere to infection control protocols, including enhanced barrier precautions and standard precautions, for multiple residents. Staff did not change gloves or perform hand hygiene after providing care, handling soiled items, or before administering medications. A resident with a permacath lacked proper signage and PPE, and staff were unaware of necessary precautions. These lapses increased the risk of infection spread.
A resident with muscle weakness and spinal stenosis was observed with food particles on their clothing, which they found bothersome. The facility's policy on dignity was not followed, as staff failed to keep the resident's clothes clean, impacting their dignity and self-worth. The RN and DON acknowledged the issue, noting the importance of maintaining cleanliness to uphold residents' dignity.
A facility failed to obtain informed consent from a resident before administering Lorazepam, a psychoactive medication. The resident, who was cognitively independent but required physical assistance, was not informed of the risks and benefits of the medication. The facility's policy requires consent prior to administering such medications, which was not followed, as confirmed by staff and the resident.
A resident with severe cognitive impairment and physical limitations did not receive timely assistance for a diaper change, despite multiple requests. The CNA prioritized other tasks, delaying care and potentially risking the resident's well-being. Facility policies on accommodating resident needs and supporting ADLs were not followed.
A resident with mobility issues was using a wheelchair with torn tires, which posed a risk of falls and injury. The maintenance department was not informed about the damage, and the facility's policy on maintaining safe equipment was not followed.
A resident with respiratory failure and COPD did not receive continuous oxygen as ordered, as the nasal cannula was not replaced after restroom use. The resident had to request assistance to have the oxygen restored, which was confirmed by an LVN as a deviation from the physician's order, risking respiratory complications.
A facility failed to adhere to a physician's order for a fluid restriction of 1200 cc per day for a resident with end-stage renal disease on dialysis. Documentation showed discrepancies in fluid intake records, with missing entries and recorded intakes exceeding prescribed amounts. The resident was observed with a full pitcher of water, and staff interviews revealed a lack of adherence to the fluid restriction protocol. The facility's policy on end-stage renal disease care was not followed.
A facility failed to assess and obtain informed consent for the use of bedside rails for a resident with a history of cerebral infarction and falls. Despite physician orders for the rails as an enabler, no consent was documented, and only two assessments were conducted. The facility's policy requires alternatives, interdisciplinary evaluation, and informed consent before using bed rails, which was not followed, placing the resident at risk.
A facility failed to coordinate hospice care for a resident with severe cognitive impairment and multiple diagnoses, including cirrhosis and congestive heart failure. The CHHA did not follow the physician's order for twice-weekly visits, and no hospice care plan was developed. The DON and DPCS acknowledged these deficiencies, which could impact the resident's comfort and quality of life.
A facility failed to ensure a resident's call light was within reach, as observed when the call light was found on the floor while the resident was in bed. The resident, with a history of cerebral infarction and falls, required substantial assistance with daily activities. Staff interviews confirmed the expectation for call lights to be accessible, aligning with the facility's policy.
A resident with a femur fracture experienced a significant delay in receiving pain medication, despite having a pain management plan in place. The resident requested medication and waited nearly two hours in severe pain before it was administered. The LVN was informed of the request but delayed administration, contrary to facility protocol requiring timely medication delivery. The DON confirmed the importance of prompt pain management and communication with residents.
A facility failed to create a comprehensive care plan for a resident who refused care from certain CNAs. Despite the resident's known behavior and diagnoses of hemiplegia, paranoid schizophrenia, and bipolar disorder, no care plan addressed her refusal of care, potentially leading to inappropriate care. Staff interviews confirmed the absence of documentation for this behavior, highlighting a failure to meet the facility's policy for person-centered care plans.
A resident who underwent a left hip hemiarthroplasty did not receive an individualized care plan addressing specific post-surgery needs. The care plan lacked essential interventions such as hip precautions and monitoring for complications. Both the DON and MDS Nurse acknowledged these deficiencies, which were not in line with the facility's policy for developing comprehensive care plans.
A resident who underwent hip surgery was not properly monitored for signs of dislocation, such as uneven leg length, by the nursing staff. Despite occupational therapy noting a leg length discrepancy, no assessment was documented by the nurse practitioner, and no change of condition was completed. The resident's pain medication was ineffective, and the resident was later diagnosed with a hip dislocation at a hospital.
A resident with dementia was subjected to verbal abuse by their roommate, who also had cognitive impairments, in an LTC facility. The incident involved cursing in Spanish during a bathroom maneuver, witnessed by multiple staff members. Despite the facility's policy to protect residents from abuse, the verbal aggression was not promptly reported by all staff, highlighting a deficiency in safeguarding residents.
A resident with dementia verbally abused another resident in a LTC facility, but the incident was not reported to the State Survey Agency, ombudsman, or law enforcement within the required 2-hour timeframe. Despite staff witnessing the abuse and recognizing it as such, the facility failed to adhere to its policy on immediate reporting of abuse incidents.
A resident's call light was not within reach, as it was found tucked behind the side rail of the bed, contrary to the care plan and facility policy. The resident, with multiple fractures and intellectual disabilities, was unable to call for assistance, posing a risk of harm. Staff interviews confirmed the deficiency, highlighting the importance of call light accessibility.
A resident with hepatic encephalopathy and type 2 diabetes reported verbal abuse by two CNAs, which was not reported to external authorities as required by the facility's policy. Interviews revealed that the Administrator and Director of Nursing were unaware of the incident, and the facility failed to follow its protocol for immediate reporting and investigation, putting the resident at risk for further abuse.
A resident with angina pectoris experienced chest pain, but the attending physician was not notified immediately, contrary to facility policy. The resident reported the pain to staff in the morning, but the physician was only informed hours later, delaying necessary care. Staff interviews confirmed the delay, and the DON acknowledged the failure to follow protocol.
A facility failed to promptly conduct a STAT EKG for a resident with chest pain, resulting in a delay of several hours. The EKG, showing a Sinus Rhythm with first-degree atrioventricular block, was not communicated to the attending physician as required by policy. Staff interviews confirmed the lack of notification and documentation, highlighting a breach in protocol for timely diagnosis and treatment.
A resident with a history of aggression hit another resident, who was moderately impaired, in the face. Despite the aggressive resident's known history, the facility failed to provide adequate supervision, leading to the incident. Observations showed a lack of staff presence in the area, and no new interventions were implemented to prevent further abuse.
A facility failed to report an alleged physical abuse incident within the required two-hour timeframe. A resident with depressive disorder and epilepsy was hit by another resident, as witnessed by a CNA. The DON attempted to report the incident but did not confirm successful transmission to the SSA, resulting in a delay. The facility's policy mandates immediate reporting within two hours, which was not adhered to.
Failure to Provide and Document Foley Catheter Care per Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide and document Foley catheter (F/C) care for a resident with an indwelling urinary catheter, as required by the resident’s care plan. The resident had diagnoses including urethral discharge, dementia, and benign prostatic hyperplasia with lower urinary tract symptoms, and had an order for an 18 Fr F/C related to bladder sphincter dyssynergia due to obstructive uropathy. The resident’s care plan for an indwelling catheter related to obstructive uropathy, revised on 1/26/2026, included interventions to provide F/C care and change the catheter and catheter bag per order. The MDS assessment documented that the resident had severely impaired cognitive skills for daily decision making, was dependent for oral care, toileting, personal hygiene, dressing, and bathing, and had an indwelling urinary catheter. Record review of the resident’s electronic medical chart from 10/1/2025 through 4/8/2026 showed no physician’s order for F/C care and no documentation that F/C care was provided during that period. Treatment Nurse 2 confirmed there was neither an order nor documentation of F/C care and stated that F/C care should have been provided and documented daily by the assigned treatment nurse, describing F/C care as cleaning the genital area with soap and water, monitoring for signs of infection, ensuring the catheter is clean, not kinked, properly secured, and that the drainage bag is not touching the floor. Treatment Nurse 1 stated the resident should have had an order for F/C care and that all residents with F/Cs should receive such care and have it documented. Registered Nurse 2 reported the facility did not have a policy specific to F/C care but stated that F/C care should be provided to every resident with a Foley catheter and that this resident should have been receiving F/C care during the reviewed period. The facility’s Comprehensive Person-Centered Care Plan policy required development and implementation of a comprehensive care plan with measurable objectives for each resident.
Failure to Provide and Document Ordered Colostomy Care
Penalty
Summary
The facility failed to provide and document colostomy care as ordered and per policy for one resident. The resident was admitted with diagnoses including partial intestinal obstruction, colostomy status, and chronic kidney disease, and had a documented left abdominal colostomy. An MDS assessment showed the resident had moderately impaired cognitive skills for daily decision making and required assistance ranging from partial/moderate to total dependence for hygiene, toileting, dressing, and bathing. Physician’s orders dated 8/27/2025 directed that colostomy care be provided and the colostomy bag emptied as needed, and the resident’s care plan instructed that the colostomy appliance be changed per physician’s orders. Review of the Treatment Administration Record from 11/16/2025 through 12/6/2025 showed blank entries for colostomy care and colostomy bag emptying, and concurrent review of the electronic medical record for the same period revealed no documentation that colostomy care or colostomy bag replacement had been provided. The treatment nurse confirmed there was no documentation of colostomy care or bag changes during that time and stated that, per facility protocol, such care should be documented on the TAR or in a progress note. A registered nurse similarly stated that colostomy care includes checking for signs of infection, cleaning the stoma site, and emptying or changing the colostomy bag, and that this care must be documented when done. The facility’s colostomy/ileostomy care policy required documentation of the date and time care was provided, the staff member’s name and title, skin condition and signs of infection, resident tolerance, refusals and reasons, and the signature and title of the person recording the data, which was not present for the identified period.
Failure to Address Grievances and Ensure Equal Access to Shared Restroom
Penalty
Summary
The deficiency involves the facility’s failure to address resident grievances and ensure equal access to a shared restroom and related services for roommates of a cognitively intact resident. One resident with major depressive disorder and anxiety, who required varying levels of assistance with ADLs but had intact decision-making skills, reported that when previously sharing a room with another resident, she was not allowed by that roommate to use the in-room restroom or the call light. She stated she had reported these concerns to the Administrator and raised them multiple times in resident council meetings but did not feel her concerns were heard, and she believed the facility avoided assigning a roommate to the controlling resident because that resident would “raise a fuss.” Another resident with major depressive disorder and COPD, also cognitively intact and requiring assistance with ADLs, reported that the same controlling resident would not allow any roommates to use the shared restroom or allow CNAs to obtain water from that restroom to provide care to the roommates. This resident stated that CNAs instead used the restroom in her room to get water to bathe the controlling resident’s previous roommate, and that the Activity Director was aware of these concerns from resident council meetings but nothing had been done. Staff interviews corroborated that CNAs had to obtain water from other residents’ restrooms because the controlling resident would not permit use of the shared restroom, and that roommates who were able to walk were told by the controlling resident to use other residents’ restrooms rather than the shared one in their own room. The Social Services Director stated that previous roommates who could use the restroom had complained about not being allowed to use the shared restroom and often requested room changes, and acknowledged it was not acceptable for them to have to use another resident’s restroom because they had the same rights to use the shared restroom. The DON acknowledged hearing about the shared bathroom complaints during a recent resident council meeting but had not yet spoken to the controlling resident, and stated there should have been follow-up and closure provided to the residents who raised concerns. The DON and an RN both affirmed that roommates had the right to use the shared restroom and that CNAs should be able to use it to obtain water for care. The facility’s Resident Rights policy stated that residents have the right to communication with and access to services and to voice grievances and have the facility respond, but the reported and observed handling of these complaints showed that the concerns of the affected residents were not addressed or resolved.
Improper Storage of Multiple Oxygen Tanks in Resident Room and Restroom
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s environment free from accident hazards by improperly storing multiple oxygen tanks in and near the resident’s restroom and room. The resident, who had COPD, a history of falls, and was assessed as at risk for falls, was cognitively intact and required setup assistance for toileting hygiene, showering, lower body dressing, and footwear, but was otherwise independent with eating, oral and personal hygiene, and upper body dressing. During observation, surveyors noted three oxygen tanks inside the resident’s restroom and two oxygen tanks just outside the restroom near the wall on the left side of the room. Staff present acknowledged that the resident had many oxygen tanks in the room and restroom. In interviews, an LVN stated that the three oxygen tanks in the restroom and two by the foot of the bed should be removed because they could be a safety hazard for the resident. An RN stated that oxygen tanks not in use should be stored in the oxygen storage room, not in a resident’s room, and that only one oxygen tank for the resident’s use should be in the room, further stating that five oxygen tanks in the room should not be allowed because they are a safety and trip hazard. The DON stated that the five oxygen tanks stored in the resident’s room were a big hazard because the resident could trip, fall, and might hit her head on the oxygen tank, and also described them as a fire hazard that should be stored in the oxygen storage room. Review of facility policies showed that the Fire Safety and Prevention policy prohibited storing oxygen cylinders in any resident’s room or living areas, and the Safety and Supervision of Resident policy stated the facility strives to make the environment as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents are facility-wide priorities.
Malfunctioning Bed Rails Not Maintained in Safe Working Order
Penalty
Summary
The facility failed to ensure that a resident’s bed rails were safe, functional, and in good working condition in accordance with its policies. The resident had diagnoses including lack of coordination and abnormalities of gait and mobility, and an MDS assessment documented severe cognitive impairment and a need for partial/moderate assistance with bed mobility, transfers, and sit-to-stand activities. A physician’s order authorized bilateral 1/3 bed rails as an enabler to aid in mobility, positioning, and transfer. During observation, the resident was found lying in bed asleep with both 1/3 bilateral bed rails in the raised position. When checked by a Licensed Vocational Nurse, both bed rails were found to be stuck and could not be lowered, contrary to the expectation that they should lower easily to allow the resident to get in and out of bed safely. A Maintenance Assistant subsequently examined the bed rails, removed and reinstalled them, and was still unable to lower the left bed rail. The Maintenance Assistant stated that the bed rails on this type of bed were not working properly, despite being reinstalled in the correct holes. A CNA reported that bed rails should be working properly because staff raise and lower them when changing and positioning residents. The DON stated that residents’ beds should be in good working order for residents’ safety and ease of use. Review of the facility’s Maintenance Service policy indicated that the maintenance department is responsible for maintaining equipment in a safe and operable manner at all times, and the Bed Safety and Bed Rails policy required that any worn or malfunctioning bed system components be repaired or replaced using components that meet manufacturer specifications. These observations and statements showed that the resident’s bed rails were malfunctioning and not maintained in accordance with facility policy.
Failure to Maintain Dignity and Accommodate Residents’ TV and Room-Transfer Needs
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to dignity, self-determination, and accommodation of needs related to room transfer and television access. One resident with bilateral primary osteoarthritis of the hip and a right artificial knee joint, who had intact cognition and required varying levels of assistance with ADLs, was transferred from one room to another. During the move, the maintenance assistant placed all of the resident’s clothes and personal belongings from the prior room onto the bed in the new room and moved the resident around 1 PM. Staff, including CNAs and LVNs, acknowledged that CNAs were responsible for putting residents’ belongings away in closets or drawers during a room move so the resident could access the bed. However, the belongings were left on the bed, and the resident reported having to sit in a wheelchair for approximately 2½ hours, unable to lie down. The resident’s caregiver corroborated that, upon arrival, the resident was in the wheelchair with clothes and personal items still on the bed, and that the resident appeared upset and reported having been left waiting. The same resident also reported that he did not read and preferred to watch TV, but the facility never provided a functional TV remote control after the room transfer. The maintenance assistant stated that the remote control available was a universal controller that was not compatible with the resident’s specific TV brand and that the facility did not have a suitable remote for that TV. The DON stated that the TV remote control should be functional so residents can watch the programs they want. As a result, the resident’s stated preference to keep up with the news, documented as somewhat important on the MDS, was not accommodated because he lacked a working remote to operate the TV in his room. A second resident, with generalized muscle weakness and difficulty walking, also had intact cognition and required extensive assistance with ADLs. This resident’s MDS documented that keeping up with the news was very important. During observation and interview, the resident demonstrated that not all TV channels worked, specifically turning to a news channel and another channel that displayed blurred or unclear screens compared to other channels, and stated that it was bothersome not to be able to watch those news stations. The maintenance assistant confirmed that CNN and Channel 5 on this resident’s TV did not work and reported having informed the administrator and attempting to get management to change the cable service/company. The DON stated that all channels should work so residents can watch the programs they want. These conditions showed that the facility did not ensure residents had functional television access consistent with their expressed preferences for news programming.
Failure to Provide Ordered Restorative Nursing Ambulation Services
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing assistant (RNA) services as ordered for a resident with limited range of motion and mobility needs. The resident was admitted with bilateral primary osteoarthritis of the hip and a right artificial knee joint, and an MDS dated 9/11/2025 showed the resident had intact cognition and required varying levels of assistance with ADLs, including substantial/maximal assistance for showering and partial/moderate assistance for lower body dressing and footwear. A physician’s order dated 12/15/2025 directed that the resident receive RNA ambulation services daily, three times per week, for 60 feet with a front-wheeled walker and gait belt as tolerated. Review of RNA documentation for December 2025 and January 2026, along with interviews with RNA staff and the Director of Staff Development (DSD), showed that RNA services were not provided or documented on 12/22/2025, 12/26/2025, and 1/2/2026. During observation and interview, the resident reported that RNA sessions were supposed to occur three times per week but that staff did not come as scheduled. The RNA log and documentation reviewed with the DSD confirmed that the resident received only one RNA session during the week of 12/22/2025–12/28/2025 and two sessions during the week of 12/29/2025–1/4/2026, instead of the ordered frequency. The DSD stated that if RNA services were not documented, they were not done, and acknowledged that RNA services should be consistently provided as scheduled to maintain functional mobility and prevent decline. The DON stated that RNA services are important to help maintain residents’ mobility and that inconsistent provision could potentially cause a decline, and further stated that the resident did not have a care plan for RNA services, which should have been in place to guide staff. Review of the facility’s Restorative Nursing Services policy indicated that restorative goals and objectives are individualized, resident-centered, and outlined in the resident’s plan of care, which was not done in this case.
Failure to Provide Respiratory Care Services per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide respiratory care services in accordance with its policy and physician orders for two residents. One resident, with diagnoses including acute and chronic respiratory failure, asthma, and dementia, had a physician order for continuous oxygen at 3 liters per minute (lpm) via nasal cannula. On multiple observations, the resident was found not wearing the nasal cannula, with the oxygen tubing resting on the chest, and the oxygen concentrator set at 2.5 lpm instead of the ordered 3 lpm. Both the DON and an LVN confirmed the incorrect oxygen setting and acknowledged that the resident was not receiving oxygen as ordered. Another resident, diagnosed with COPD, anemia, and dementia, had a physician order for continuous oxygen at 2 lpm via nasal cannula and instructions to notify the physician if oxygen saturation fell below 92%. The resident's oxygen saturation was documented as 91% on three separate occasions, but there was no evidence in the medical record or SBAR documentation that the physician was notified as required. The DON confirmed the lack of documentation and stated that the licensed staff did not call the physician regarding the low oxygen saturation levels. Facility policy on oxygen administration required staff to review physician orders, observe residents to ensure oxygen is being tolerated, and document the rate, route, and assessment data in the medical record. The policy also required reporting relevant information in accordance with professional standards. These requirements were not met for either resident, as evidenced by the lack of proper oxygen administration and failure to notify the physician of low oxygen saturation.
Failure to Maintain Safe and Sanitary Environment Due to Unaddressed Water Leaks
Penalty
Summary
The facility failed to maintain the physical environment in a safe and sanitary condition by not preventing or promptly addressing water leaks in the ceiling of a hallway and a resident's room. Observations revealed a large hole with visible water damage in the ceiling of the hallway in front of the oxygen room, with water leaking into a bin and towels placed on the floor to absorb excess water. Staff interviews confirmed that the water leakage began during a period of rain, and maintenance staff were either unavailable or only began repairs after the issue had persisted for several days. The facility's policy required maintenance to be provided to all areas and for the environment to be kept in good repair, but these standards were not met during the incident. In a resident's room, grayish discoloration and watermarks were observed on the ceiling and wall, and the resident reported that water had leaked from the ceiling the previous night, soaking personal items. The resident, who had significant medical needs including congestive heart failure, chronic respiratory failure with hypoxia, and generalized muscle weakness, was at risk of being directly affected by the leak. Staff confirmed the presence of water damage and acknowledged that the resident could get wet and might not be able to sleep due to the leak. The maintenance assistant was unaware of the issue until it was pointed out during the survey, and there was no documentation of the leak in the maintenance log or the facility's electronic reporting system. Further review of facility policies indicated that maintenance requests should be logged and prioritized, with work orders picked up daily from the nurses' station. However, staff interviews and record reviews revealed that the required reporting and communication procedures were not followed, as no maintenance requests were filed for the leaks, and the maintenance assistant did not check the log as required. The lack of timely reporting and response contributed to the ongoing unsafe and unsanitary conditions in both the hallway and the resident's room.
Failure to Document Indication and Monitoring for Foley Catheter Insertion
Penalty
Summary
Staff failed to follow facility policy and procedures regarding the insertion and documentation of an indwelling (Foley) catheter for one resident. The resident was admitted with diagnoses including hypertension, osteoarthritis, and lack of coordination, and was assessed as having modified independence in cognitive skills and occasional urinary incontinence. The physician's order allowed for an in-and-out catheterization, with a Foley catheter to remain in place if residual urine exceeded 300 milliliters, but the order did not specify the indication for catheter use as required by facility policy. Upon review, there was no documentation of the indication for the Foley catheter, the time of insertion, or monitoring of intake and output in the resident's progress notes. Additionally, there was no documentation regarding the urine output, color, clarity, or the resident's tolerance of the procedure. The care plan for the Foley catheter was not developed at the time of insertion, and the required monitoring and documentation were not completed according to policy. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy and procedures were not followed. The staff acknowledged that the order lacked an indication and that documentation was incomplete. The Director of Nursing also confirmed that the comprehensive, person-centered care plan was not developed or implemented at the time of catheter insertion, as required by facility policy.
Failure to Document Change in Resident Condition
Penalty
Summary
The facility failed to document an episode of dizziness and vomiting experienced by a resident with a history of hemiplegia, hemiparesis, and left hand contracture following a cerebral infarction. The resident reported feeling dizzy and vomiting a few days prior, and stated that she informed a registered nurse about these symptoms. However, a review of the resident's nurses' progress notes revealed no documentation of these events on the relevant date. Licensed staff confirmed that such symptoms should have been recorded in the medical record to allow for appropriate follow-up and monitoring. Further review of the resident's care plan indicated that any chief complaint of dizziness should be documented, and the facility's policy on charting and documentation required that all changes in a resident's condition be objectively, completely, and accurately recorded in the medical record. The Director of Nursing confirmed that documentation of episodes and frequency of dizziness was necessary according to the care plan. The lack of documentation resulted in an inaccurate representation of the care provided to the resident.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Monitor Effectiveness of Psychotropic Medication
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident was free from unnecessary drugs by not properly monitoring the effectiveness of Ambien, a psychotropic medication prescribed for insomnia. The resident, who had diagnoses including insomnia and anxiety disorder, was admitted with cognitive skills intact and required varying levels of assistance with daily activities. Physician orders specified that the resident’s hours of sleep should be monitored every evening and night shift, particularly when Ambien was administered as needed for insomnia. Record reviews revealed that the Medication Administration Record (MAR) only included check marks for monitoring sleep, rather than documenting the specific number of hours slept as required by the physician’s order. Interviews with the resident, a Licensed Vocational Nurse, and the Assistant Director of Nursing confirmed that the MAR did not accurately reflect the number of hours of sleep, and staff acknowledged that this information was necessary to determine the medication’s effectiveness. The facility’s policy also required adequate monitoring for efficacy and adverse consequences of psychotropic medications, which was not followed in this case.
Failure to Document, Notify Physician, and Monitor Change of Condition After Resident Head Injury
Penalty
Summary
The facility failed to document an assessment, notify the attending physician, initiate a Change of Condition (CoC), and monitor the CoC for a resident who reported hitting her head in the bathroom. The resident, who had a history of cerebral infarction and dementia but was assessed as having intact cognition, informed the Director of Staff Development (DSD) that she had hit her head on a grab bar. Despite this report, there was no documentation in the resident's progress notes regarding the incident, assessment, or any subsequent monitoring or treatment. Interviews with the DSD and Director of Nursing (DON) confirmed that the DSD did not notify the resident's physician, document an assessment, or initiate a CoC as required by facility policy. The facility's policy mandates prompt notification of the physician and documentation of any changes in a resident's condition, including accidents or incidents. The DON acknowledged that the required steps were not taken, and the incident was not properly managed or recorded in the resident's medical record.
Failure to Develop Comprehensive Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, resident-centered care plan to prevent falls for a resident with significant risk factors. The resident had a history of falls, bilateral leg weakness, and was dependent on staff for bed mobility and incontinent care. The resident was also using a low air loss mattress (LALM), which increases the risk of falls due to its shifting surface. Despite these factors, the care plan did not specify the type or number of staff assistance required during incontinent care, nor did it include interventions tailored to the resident's needs while on the LALM. On the day of the incident, a CNA was providing incontinent care to the resident and prompted the resident to turn. The resident subsequently slid off the bed and fell to the floor, sustaining complaints of pain but no visible bruising or discoloration. The CNA was unaware of the recommendation that two staff members should be present during incontinent care for residents on a LALM. Interviews with other staff, including another CNA, the RN, the DON, and the MDS nurse, confirmed that the care plan lacked specific instructions regarding the required assistance and interventions to prevent falls during such care. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. However, the care plan for this resident did not address the specific risks associated with the resident's condition and equipment, nor did it communicate the necessary precautions to staff. This omission directly contributed to the resident's fall during routine care.
Resident's Right to Voice Grievances Violated
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as required by their policy, by not allowing the resident to voice grievances without fear of discrimination or reprisal. The resident, who was diagnosed with major depressive disorder, hemiplegia, and hemiparesis, was independent in cognitive skills for daily decision-making but required substantial assistance with personal care. During an interview, the resident reported that a Certified Nursing Assistant (CNA) told her that if she continued to complain about the facility's CNAs, no one would want to work with her. This statement made the resident feel retaliated against and discouraged her from voicing future grievances. The Director of Staff Development (DSD) confirmed that the CNA admitted to making the statement, which was deemed disrespectful and contrary to the facility's policy. The facility's policy, titled 'Resident Rights,' clearly states that residents have the right to voice grievances without fear of discrimination or reprisal and that employees must treat all residents with kindness, respect, and dignity. The DSD acknowledged that the CNA's actions were inappropriate and not in line with the facility's policy, which could potentially prevent the resident from expressing any future concerns.
Facility Fails to Maintain Homelike Environment Due to Chipped and Peeling Paint
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the presence of chipped and peeling paint in 10 out of 43 resident rooms. Observations revealed that several rooms, including Rooms A, B, C, D, E, F, G, H, I, and J, had areas of chipped or peeling paint, as well as unpainted patched areas. These conditions were noted during various observations conducted by surveyors and confirmed by the Maintenance Supervisor, Director of Nursing, and Administrator. The facility's policy on maintaining a homelike environment, revised in February 2021, emphasizes the importance of providing a comfortable setting for residents, which was not adhered to in this instance. Interviews with facility staff, including the Maintenance Supervisor and Director of Nursing, confirmed the need for repainting to ensure a homelike environment. The Administrator acknowledged the issue, stating awareness of the need for repairs. The facility's maintenance policy, revised in December 2009, outlines the responsibility of maintenance personnel to keep the building in good repair, which was not fulfilled in this case. The deficient practice had the potential to create an unsafe and unclean environment, posing a risk for physical discomfort to the residents.
Improper Food Handling and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as per its policy and procedure, which resulted in several opened and expired food items being improperly labeled or not discarded. During an initial kitchen tour, the Dietary Supervisor (DS) identified several opened items, such as bottles of seasoning salt, ground ginger, pure vegetable oil, and plastic bags of pasta, that were not labeled with a proper open date and used by date. Additionally, expired items like browning and seasoning sauce and food coloring were found in the kitchen, which should have been discarded according to the facility's policy. The DS admitted to not knowing why the food items were not labeled correctly or why expired items were still stored in the kitchen. The facility's policy, as reviewed, indicated that no food should be kept beyond its expiration date and that all items should be labeled with either a delivery date or a use-by date. The failure to follow these procedures has the potential to expose residents to pathogens, increasing the risk of foodborne illnesses.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to ensure staff adhered to enhanced barrier precautions and standard precautions, leading to potential infection risks among residents. For Resident 6, staff members were observed not changing gloves and not performing hand hygiene after providing peri-care, which involved touching the resident and her wheelchair with the same gloves. This was acknowledged by the staff, who admitted the oversight could spread infection. Similarly, for Resident 88, a staff member failed to doff gloves and perform hand hygiene after emptying a urinal, subsequently touching the resident's personal belongings, which was also recognized as a lapse in infection control. Resident 28, who had a permacath for dialysis, did not have enhanced barrier precaution signage or personal protective equipment available outside the room. A Licensed Vocational Nurse (LVN) was observed taking the resident's blood pressure and heart rate without wearing gloves or a gown and did not perform hand hygiene before preparing and administering medications. The LVN admitted to not being aware of the necessary precautions for residents with central lines, and the Infection Preventionist Nurse confirmed the oversight in not including the resident on the enhanced barrier precautions list. For Resident 18, an LVN failed to perform hand hygiene before and after checking the resident's heart rate and before preparing medications. This was acknowledged by the LVN and the Director of Nursing, who emphasized the importance of hand hygiene in preventing the spread of microorganisms. Additionally, laundry staff were observed handling clean and soiled linens without performing hand hygiene, contrary to the facility's policy. These practices collectively posed a risk of spreading infections among residents and staff.
Resident Dignity Compromised by Unclean Clothing
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 49, was treated with respect and dignity by not keeping the resident's clothes clean and free of food particles. Resident 49, who was admitted with diagnoses of muscle weakness and spinal stenosis, was observed with yellow food particles on their clothing. The resident expressed discomfort with the food particles, indicating that it bothered them. The Minimum Data Set (MDS) assessment indicated that Resident 49 required assistance with eating and dressing, highlighting the need for staff support in maintaining the resident's dignity. During observations and interviews, it was noted that the resident's clothes had food particles, specifically eggs, which were acknowledged by a Registered Nurse (RN) and the Director of Nursing (DON) as inappropriate and not in line with the facility's policy on dignity. The facility's policy emphasized the importance of providing a dignified dining experience and maintaining residents' cleanliness to promote their well-being and self-esteem. The failure to adhere to this policy resulted in a deficiency related to the resident's dignity and self-worth.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 88, was informed in advance of the risks and benefits of a proposed care plan involving the use of psychoactive medication. Specifically, the facility did not obtain informed consent prior to administering Lorazepam, an antianxiety medication, to Resident 88. The resident was admitted with multiple diagnoses, including an unspecified fracture of the left fibula, dislocation of the left ankle joint, gout, and unsteadiness on feet. The Minimum Data Set (MDS) indicated that the resident was independent in cognitive skills for daily decision-making but required substantial assistance with certain physical activities. Despite this, the resident was administered Lorazepam without prior consent, as confirmed by both the MDS Coordinator and the resident himself. The deficiency was further highlighted during interviews and record reviews, where it was revealed that the facility's policy and procedure required obtaining consent from the resident or responsible party before placing an order for psychoactive medication. The Director of Nursing acknowledged that the facility should have obtained consent prior to administering the medication. The facility's policy on Resident Rights, revised in February 2021, mandates that residents be informed of and participate in their care planning and treatment, which was not adhered to in this case.
Failure to Prioritize Resident's ADL Needs
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 77, received the necessary care and services to maintain good personal hygiene, specifically in relation to activities of daily living (ADL). Resident 77, who was admitted with diagnoses including generalized muscle weakness, difficulty walking, and neuromuscular dysfunction of the bladder, was observed to have severely impaired cognitive skills and was dependent on assistance for personal hygiene and toileting. On the day of the incident, Resident 77 activated the call light multiple times requesting a diaper change, but the Certified Nursing Assistant (CNA 3) prioritized other tasks over attending to the resident's immediate needs. Despite the resident's repeated requests for assistance, CNA 3 delayed attending to Resident 77, opting instead to assist another resident and change bed sheets in a different room. This delay was noted by other staff members, including the Central Supply Director and the Infection Prevention Nurse, who were involved in trying to locate CNA 3 to address Resident 77's needs. The Director of Nursing later confirmed that staff should prioritize resident care and attend to their needs within five minutes. The facility's policies on accommodating resident needs and supporting ADLs were not adhered to, resulting in a deficiency related to unmet resident needs and potential risks to the resident's well-being.
Wheelchair Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 88, was free from accident hazards by not providing a wheelchair with properly functioning tires. Resident 88, who was admitted with a fracture of the left fibula, dislocation of the left ankle joint, gout, and unsteadiness on feet, was observed using a wheelchair with torn tires. The resident reported that the wheelchair brakes did not work well, and observations confirmed difficulty in stopping the wheelchair, posing a risk of falls and injury. Interviews with the Maintenance Supervisor and the Director of Nursing revealed that the maintenance department was not informed about the damaged wheelchair tires, which were acknowledged as unsafe for use. The facility's policy indicated that the maintenance department is responsible for ensuring equipment is safe and operable, but this was not adhered to in this instance, leading to the deficiency.
Failure to Administer Continuous Oxygen as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care services for Resident 294 by not administering oxygen according to the physician's orders. Resident 294, who was admitted with acute and chronic respiratory failure, COPD, and CHF, had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. However, during an observation, it was noted that the resident's nasal cannula was not in place after being assisted to the restroom by a Certified Nurse Assistant (CNA 6). The nasal cannula was found on the pillow, out of the resident's reach, and the resident had to request assistance to have it replaced. The Licensed Vocational Nurse (LVN 3) confirmed that the oxygen order was for continuous use and emphasized the importance of adhering to the physician's order to prevent complications such as shortness of breath. The facility's policy on oxygen administration requires verification and adherence to physician's orders, which was not followed in this instance. This oversight placed Resident 294 at risk for respiratory distress and other complications due to the interruption in oxygen therapy.
Failure to Implement Fluid Restriction for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to implement the physician's order for a fluid restriction of 1200 cc per day for a resident with end-stage renal disease dependent on dialysis. The care plan specified a breakdown of fluid intake between dietary and nursing, but documentation showed discrepancies in fluid intake records. There were missing entries for breakfast fluids on multiple days, and recorded fluid intakes exceeded the prescribed amounts on several occasions. Additionally, the resident was observed with a full pitcher of water at the bedside, contrary to the fluid restriction order. Interviews with the resident and staff revealed a lack of adherence to the fluid restriction protocol. The resident was aware of the fluid restriction but reported receiving pitchers of water daily, which were refilled by staff. A Licensed Vocational Nurse confirmed the risk of shortness of breath from excess fluid and acknowledged the error in providing a full pitcher of water. A Certified Nursing Assistant admitted to not knowing the exact fluid restriction amount and emphasized the importance of accurate documentation of fluid intake. The facility's policy on end-stage renal disease care was not followed, as the comprehensive care plan did not reflect the resident's needs related to dialysis care.
Failure to Assess and Obtain Consent for Bedside Rail Use
Penalty
Summary
The facility failed to properly assess and obtain informed consent for the use of bedside rails for one resident, identified as Resident 15. The resident, who had a history of cerebral infarction, major depressive disorder, and falls, was observed with both middle sections of the bedside rails up. Despite the presence of physician orders for the use of bedside rails as an enabler for mobility, positioning, and transfer, there was no documented consent from the resident or their family. The MDS nurse confirmed the absence of consent and stated that the family should have been informed of the risks and benefits before the use of the rails. The Director of Nursing confirmed that only two Bedside Rail Utilization Assessments were conducted, and no consent was obtained prior to the use of the rails. The facility's policy, revised in August 2022, prohibits the use of bed rails unless specific criteria are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The failure to adhere to these protocols placed the resident at risk for potential accidents, such as entrapment or falls, due to improper use of the bedside rails.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and hospice staff for a resident, identified as Resident 76, who was receiving hospice services. The deficiency involved the failure of the Certified Home Health Agency (CHHA) staff to adhere to the physician's order to visit and provide care to the resident twice per week. The review of records indicated that the CHHA only visited once a week during two specific weeks, which was not in compliance with the physician's order. Additionally, there was no hospice care plan developed for Resident 76, which is essential for guiding hospice staff in providing appropriate care. Resident 76 was admitted to the facility with diagnoses including cirrhosis of the liver, congestive heart failure, and alcohol dependence. The resident was severely impaired in cognitive skills and required substantial assistance with daily activities. The facility's Director of Nursing acknowledged the discrepancy in the frequency of CHHA visits and the absence of a hospice care plan in the resident's hospice binder. The Director of Patient Care Service confirmed the missed visits and emphasized the importance of following the physician's order to ensure the resident received the necessary hospice care and services to promote comfort and quality of life.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, specifically Resident 15. This deficiency was identified during an observation where the call light was found on the floor, out of the resident's reach, while the resident was sleeping in bed. The facility's policy requires that call lights be within reach to allow residents to call for assistance, especially during emergencies. Interviews with staff, including a CNA, an RN, and the Director of Nursing, confirmed that call lights should be accessible to residents. Resident 15 had a history of cerebral infarction, major depressive disorder, and a history of falling, which necessitated the need for the call light to be within reach as part of their care plan. The resident's Minimum Data Set indicated they required substantial assistance with various activities of daily living, including toileting and personal hygiene, and supervision with oral hygiene. The failure to have the call light within reach could have impeded the resident's ability to call for help when needed, as outlined in the facility's policy.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who verbalized experiencing significant pain. The resident, who was admitted with a displaced subtrochanteric fracture of the left femur, difficulty in walking, and anxiety disorder, was on a pain management regimen that included opioid medications. Despite having orders for pain medications such as oxycodone and tramadol, the resident experienced a delay in receiving pain relief after requesting medication. On the day of the incident, the resident requested pain medication and had to wait almost two hours before receiving it, during which time the resident was in severe pain, rated 7 out of 10 on the pain scale. The Licensed Vocational Nurse (LVN) was informed of the request but did not administer the medication promptly, citing the resident's engagement with a surveyor as a reason for the delay. The facility's protocol required that pain medications be administered as soon as possible when requested, but this was not adhered to in this instance. Interviews with the Director of Nursing (DON) and review of the facility's policies confirmed that the facility's protocol was to administer pain medication promptly and to communicate with residents about any delays. The failure to follow these protocols resulted in the resident experiencing unnecessary pain and distress. The facility's policies emphasized the importance of timely pain management and communication with residents to prevent anxiety and discomfort while waiting for medication.
Failure to Develop Resident-Centered Care Plan for Refusal of Care
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident who exhibited behavior of refusing care from certain Certified Nursing Assistants (CNAs). This deficiency was identified during a review of the resident's care plan history, which revealed that no care plan was created to address the resident's refusal of care from CNAs she did not like. Interviews with facility staff, including a CNA and a Licensed Vocational Nurse (LVN), confirmed that the resident was known to refuse care from specific CNAs, and that this behavior was not documented in a care plan. The absence of a care plan for this behavior could lead to staff being unaware of the resident's preferences, resulting in inappropriate care. The resident in question was admitted with diagnoses including hemiplegia, paranoid schizophrenia, and bipolar disorder. Despite being assessed with intact cognition, the resident was dependent on assistance for various activities of daily living. The facility's policy requires a comprehensive, person-centered care plan to be developed and implemented for each resident, including measurable objectives and timetables to meet their needs. However, the lack of a care plan addressing the resident's refusal of care from certain CNAs indicates a failure to adhere to this policy, potentially compromising the continuity and appropriateness of care provided to the resident.
Failure to Implement Individualized Care Plan for Post-Surgery Resident
Penalty
Summary
The facility failed to develop and implement an individualized resident-centered care plan for a resident who underwent a left hip hemiarthroplasty due to a left hip fracture. The resident was admitted with diagnoses including left hip hemiarthroplasty, left hip fracture, and hypertension. The Minimum Data Set (MDS) assessment indicated the resident was moderately impaired in cognitive skills for daily decision-making and required assistance with various activities of daily living. However, the care plan initiated did not include specific interventions related to the resident's hip surgery, such as hip precautions and monitoring for potential complications. During interviews, both the Director of Nursing (DON) and the MDS Nurse acknowledged the care plan's deficiencies. The DON noted the absence of specific aftercare interventions for the hip surgery, such as instructions to avoid bending and flexing the hip and monitoring leg length for potential dislocation. The MDS Nurse confirmed the care plan was incomplete, lacking necessary interventions like hip precautions and monitoring for unrelieved pain or symptoms of pulmonary embolism. The facility's policy requires a comprehensive, person-centered care plan to be developed within a specific timeframe, but this was not adequately followed for the resident in question.
Failure to Monitor Post-Surgical Resident Leads to Hip Dislocation
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident who had undergone a left hip hemiarthroplasty due to a left hip fracture. The licensed nursing staff did not monitor the resident for signs of hip dislocation, such as uneven leg or hip length. There was no documented evidence that the resident's bilateral hips and legs were assessed during a nurse practitioner's visit, and a change of condition was not completed when the resident was assessed as having asymmetrical hips and legs. The resident was admitted to the facility with diagnoses including a left hip hemiarthroplasty and hypertension. Occupational therapy notes indicated a length discrepancy in the resident's left leg, and nursing was informed. However, the nurse practitioner did not document any assessment of the resident's bilateral lower extremities, and no new doctor's orders were placed. The resident's pain medication was noted as ineffective, and the resident eventually went to a hospital where a left prosthetic hip dislocation was diagnosed. Interviews with facility staff, including the director of nursing, revealed that there was no specific policy for post-hip surgery care, and the licensed nurses were only monitoring for pain, swelling, and discoloration. The staff failed to assess and monitor the symmetry of the resident's legs and hips, which could indicate a hip dislocation. The facility's policy and procedure for surgery-related management did not specifically address monitoring for leg length discrepancies, and the change in the resident's condition was not documented or communicated effectively to the physician.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse, a form of mental abuse, as per their policy and procedure. The incident involved two residents, where one resident, diagnosed with dementia and severely impaired cognitive skills, was subjected to verbal aggression by their roommate. The roommate, also diagnosed with Alzheimer's disease and dementia, was heard cursing in Spanish while attempting to maneuver to the bathroom, which was obstructed by the other resident's bedside table. This altercation was documented in the facility's records, indicating that the Director of Nursing was notified of the verbal aggression. Multiple staff members, including the Medical Records Assistant, Certified Nursing Assistant, Laundry Personnel, and Maintenance Supervisor, confirmed witnessing or hearing about the verbal abuse incident. The Laundry Personnel reported hearing the abusive language daily but did not report it due to fear of getting in trouble. The Maintenance Supervisor emphasized the importance of reporting such incidents, aligning with the facility's policy that mandates reporting and investigating all possible incidents of abuse. The facility's policy, titled 'Abuse, Neglect, Exploitation and Misappropriation Prevention Program,' revised in April 2021, clearly states the residents' right to be free from abuse and the necessity to protect them from abuse by anyone, including other residents. Despite this policy, the facility failed to prevent the verbal abuse incident, as evidenced by the repeated occurrences and lack of timely reporting by some staff members. The Director of Nursing acknowledged the verbal aggression and the need for reporting to ensure resident safety.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an allegation of verbal abuse within the required 2-hour timeframe to the State Survey Agency, the state ombudsman, and local law enforcement. This deficiency involved a resident-to-resident altercation where one resident verbally abused another. The incident was documented in a Post-Event Review form, which indicated that the Director of Nursing was notified of the verbal aggression. However, the required reporting to the appropriate authorities was not completed in a timely manner. Resident 1, who was the victim of the verbal abuse, was admitted to the facility with diagnoses including diabetes mellitus, dementia, and hypertension. The Minimum Data Set (MDS) for Resident 1 indicated severely impaired cognitive skills and a need for substantial assistance with daily activities. The altercation occurred when Resident 2, who also had severely impaired cognitive skills and required moderate assistance, became verbally aggressive towards Resident 1 due to frustration over a blocked bathroom door. Multiple staff members, including the Medical Records Assistant, Certified Nursing Assistant, Laundry Personnel, and Maintenance Supervisor, witnessed or were aware of the verbal abuse. Despite recognizing the behavior as verbal abuse, the incident was not reported to the necessary authorities within the required timeframe. The facility's policy and procedure on abuse reporting clearly stated that such incidents should be reported immediately, defined as within 2 hours, but this protocol was not followed in this case.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, identified as Resident 1. This deficiency was observed during a survey when the call light was found tucked in and hanging from the top of the side rail at the head of the bed, making it inaccessible to the resident. Resident 1, who was admitted with multiple fractures and intellectual disabilities, was noted to lack the capacity to understand and make decisions. The care plan for Resident 1 specifically indicated that the call light should be within reach due to the resident's risk for further decline in function and increased dependence in activities of daily living (ADLs). Interviews with facility staff, including a Certified Nurse Assistant (CNA2), the Director of Nursing (DON), and a Charge Nurse (CN), confirmed the deficiency. CNA2 acknowledged that the call light was not within reach and emphasized the importance of having it accessible to the resident. The DON and CN both stated that the call light should be within reach to prevent potential harm, such as the resident attempting to reach for it and risking a fall. The facility's policy on answering call lights, revised in October 2023, also indicated that call lights should be accessible to residents in various locations, including in bed.
Failure to Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its policy for abuse prevention and reporting, specifically in the case of a resident who alleged verbal abuse by two CNAs. The resident, who was admitted with hepatic encephalopathy and type 2 diabetes, reported the incident to the facility's Case Manager. The resident described the CNAs using foul language during assistance, which was communicated to the facility's leadership team but not reported to the appropriate external authorities as required by the facility's policy. Interviews with facility staff, including the Administrator, Director of Nursing, and other nursing staff, revealed a lack of awareness and action regarding the incident. The Administrator, who is the facility's abuse coordinator, was not informed of the incident, and the Director of Nursing only became aware during the survey. Staff members acknowledged that the use of foul language constitutes verbal abuse and should have been reported and investigated immediately, but this did not occur. The facility's policy mandates immediate reporting of abuse allegations to various authorities, including the state licensing agency, ombudsman, and law enforcement, within two hours. However, this protocol was not followed, resulting in the failure to report and investigate the alleged verbal abuse, thereby putting the resident at risk for further abuse. The facility's policy also requires thorough investigation and documentation of such incidents, which was not adhered to in this case.
Failure to Notify Physician of Resident's Chest Pain
Penalty
Summary
The facility failed to immediately notify the attending physician regarding a resident's left-sided chest pain, which was a violation of the facility's policy. The resident, who was admitted with a diagnosis of angina pectoris and had moderately impaired cognitive skills, reported chest pain at 8:48 AM. However, the attending physician was not notified until 11:50 AM, resulting in a delay in obtaining a stat electrocardiogram order. Interviews with staff revealed that the resident had communicated the chest pain to multiple staff members, including a CNA and a case manager, but the licensed vocational nurse (LVN) responsible did not prioritize notifying the physician or seeking assistance from the Director of Nursing (DON). The facility's policy requires prompt notification of the attending physician for any change in a resident's condition, such as chest pain, which is considered a significant change. Despite this, the LVN did not follow the protocol, leading to a delay in care. The DON and other staff members acknowledged that the chest pain should have been reported immediately to prevent potential worsening of the resident's condition. The failure to act promptly on the resident's reported chest pain was identified as a deficiency by the surveyors.
Failure to Promptly Conduct and Communicate STAT EKG Results
Penalty
Summary
The facility failed to promptly act on a STAT electrocardiogram (EKG) order for a resident who was admitted with a diagnosis of angina pectoris. The physician's order for the EKG was placed due to chest pain, but the test was not conducted until several hours later, at 9:35 PM, despite being ordered at 12:07 PM. This delay in conducting the EKG test could potentially lead to a delay in diagnosis and treatment for the resident's abnormal EKG result, which showed a Sinus Rhythm with first-degree atrioventricular block. Furthermore, the facility did not notify the attending physician of the EKG results once they were available, as required by the facility's policy. Interviews with staff, including the Director of Nursing and Licensed Vocational Nurses, revealed that the EKG results were not communicated to the physician, and there was no documentation of such notification in the resident's medical records. The facility's policy mandates that diagnostic test results be promptly communicated to the attending physician to ensure timely diagnosis and treatment, which was not adhered to in this case.
Failure to Prevent Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On April 17, 2024, Resident 2 hit Resident 1 on the right cheek. Resident 1, who was moderately impaired with cognitive skills for daily decision-making, was wheeling himself to his room when Resident 2 stopped his wheelchair, used offensive language, and struck him. Resident 2 had a history of aggressive behavior, including incidents on January 1, 2023, April 1, 2024, and April 6, 2024, where Resident 2 was aggressive towards staff and other residents. Despite Resident 2's known history of aggression and cognitive impairment, the facility did not provide adequate supervision or monitoring to prevent further incidents. Interviews with staff, including CNAs and the Director of Nursing, revealed that Resident 2 was not being supervised at the time of the incident. The Director of Nursing acknowledged that Resident 2 should have been monitored to prevent aggressive behavior towards others. Observations conducted on May 7, 2024, showed that there was no staff presence in the nursing station or hallway near the rooms of Residents 1 and 2 at various times throughout the day. The facility's policy on abuse, neglect, exploitation, or misappropriation requires the administrator to determine necessary actions for resident protection upon receiving abuse allegations. However, no new interventions were implemented for Resident 2, except for medication orders, indicating a lack of proactive measures to prevent further abuse.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse within the required two-hour timeframe to the State Survey Agency (SSA). This incident involved Resident 1, who was hit on the right cheek by another resident, Resident 2, as witnessed by a Certified Nursing Assistant (CNA 1). The incident occurred on 4/17/2024 around lunchtime, but the report was not successfully sent to the SSA within the mandated time. The Director of Nursing (DON) attempted to send the report on the same day but did not verify if the facsimile transmission was successful, resulting in a delay in reporting. Resident 1, who has a history of depressive disorder and epilepsy, was moderately impaired in cognitive skills for daily decision-making, according to the Minimum Data Set (MDS) dated 5/1/2024. The facility's policy, revised in 9/2022, requires immediate reporting of abuse allegations within two hours. However, the Administrator confirmed that the report was not sent within the required timeframe, acknowledging that if the fax line was busy, repeated attempts should have been made until confirmation of successful transmission was received.
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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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