Huntington Valley Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntington Beach, California.
- Location
- 8382 Newman Avenue, Huntington Beach, California 92647
- CMS Provider Number
- 055888
- Inspections on file
- 42
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Huntington Valley Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that staff stopped CPR on a full-code resident who remained unconscious, barely breathing, and without a blood pressure, resulting in a period without compressions before paramedics arrived and resumed resuscitation. A resident with severe cognitive impairment and post-fall hip pain did not have a PT-recommended hip/femur and knee x-ray promptly communicated to the physician, and when imaging was ordered, only hip films were completed; the same resident’s critically low Hgb was not promptly reported to the physician or family, and transfer to the ER was delayed. For this resident, staff also failed to obtain a urine specimen after a physician recommendation despite lethargy and sediment in the urine, and the resident was later hospitalized with AKI and catheter-associated UTI. In addition, several residents did not receive ordered wound, skin, and device care on multiple days, as shown by missing nurse initials on TARs and MARs, with one family member reporting a visibly cloudy catheter and filthy dressing; staffing records showed that treatment nurse coverage was missing or unsigned on some days.
A resident with full-code status was found on the floor unresponsive, pulseless, and not breathing. Nursing staff with documented BLS/CPR competencies initiated CPR, with one LVN performing chest compressions and an RN providing ventilations via Ambu bag. After approximately 18–20 minutes, staff believed a carotid pulse had returned and stopped compressions, even though the resident remained unconscious, was barely breathing, and had no blood pressure while they waited several minutes for paramedics. When the fire department arrived, they found the resident pulseless, apneic, and without compressions in progress, and they restarted manual compressions and advanced resuscitative measures. This conduct did not follow the facility’s CPR policy or BLS standards requiring continuous CPR for an unresponsive, non-breathing person until help takes over.
A resident was transferred from the facility to an acute care hospital, but staff did not complete the required Notification of Transfer/Discharge or send a copy to the State LTC Ombudsman. During record review, an RN confirmed that the electronic medical record lacked the notice and any documentation of Ombudsman notification, despite acknowledging that a change of condition form, transfer form, and notice of transfer are required for resident transfers. The interim DON later acknowledged that staff should have completed the transfer notice and provided it to the LTC Ombudsman.
A resident with no capacity for medical decisions and a history of confusion was allowed to leave for an outpatient appointment without being accompanied by a responsible person, as required by the care plan for elopement risk. The resident did not return directly to the facility and the responsible party was not informed or present, which was verified by the DON and confirmed by the responsible party.
A resident did not receive and have documented intravenous fluids (IVF) as ordered by a physician. Nursing staff failed to document the administration, monitoring, and removal of normal saline IVF from the emergency kit, and there was no evidence that the physician was notified if the IVF was not given. The required documentation was missing from the medical record, and both the administrator and DON confirmed these findings.
A resident who lacked decision-making capacity was found with an expired tube of diclofenac sodium 1% topical gel stored at the bedside, without a physician's order, care plan, or authorization for self-administration. Facility staff confirmed the medication was not permitted to be stored at the bedside and that required procedures for unauthorized medications were not followed.
A resident did not receive stat CBC and CMP laboratory tests as ordered by the physician, with no evidence in the medical record that the tests were completed. Nursing staff and laboratory interviews confirmed that the stat order was not processed or communicated as required, and there was no documentation of follow-up or notification to the physician regarding the delay. The DON and Administrator acknowledged the deficiency.
A resident with an indwelling urinary catheter did not have required monitoring of urine characteristics documented on two shifts, despite physician orders and facility policy. LVNs confirmed the lack of documentation in the TAR, and the DON acknowledged that licensed nurses are expected to follow physician orders.
Surveyors found that POLST forms for three residents were incomplete or inaccurate, missing required signatures, contact information, and documentation of consent. In some cases, verbal consents were not properly witnessed, and sections regarding artificially administered nutrition were left blank. These deficiencies were confirmed by nursing staff and the DON.
Surveyors found multiple sanitation and equipment failures in the kitchen, including a greasy stove hood, chipped and melted utensils, dirty and improperly dried kitchenware, heavily marred cutting boards, and rusted equipment such as a can opener and microwave. The Dietary Services Supervisor confirmed these deficiencies and acknowledged that items were not maintained or cleaned according to policy.
Surveyors identified multiple failures in infection prevention and control, including inaccurate infection surveillance logs, lack of Enhanced Barrier Precautions for a resident with a central line, and repeated lapses in hand hygiene by staff during resident care activities such as feeding, medication administration, and wound care. These deficiencies were confirmed by staff and leadership, and involved both direct care and documentation practices.
A resident was found self-administering Systane eye drops without being assessed as able or willing to do so, and without a physician's order or care plan documentation. Facility staff confirmed the resident should not have had the medication at the bedside, and required assessments and documentation were missing.
The facility did not maintain copies of executed advance directives in the medical records for two residents and failed to provide written information or assistance on formulating advance directives to two other residents or their responsible parties, as confirmed by staff interviews and record reviews.
A nurse administered insulin to a resident without allowing the alcohol at the injection site to air dry, contrary to facility policy and manufacturer guidelines. The nurse and DSD confirmed that proper training was provided, and both acknowledged the importance of letting the site dry before injection.
A resident with limited ROM had a physician's order for a left knee extension splint, but staff failed to document the times of application and removal, and did not perform or record required skin assessments during splint use. This omission was confirmed by staff interviews and review of the care plan and medical record.
A resident with an indwelling urinary catheter was repeatedly observed with cloudy urine and sediments in the catheter tubing, but nursing staff did not complete required change of condition documentation, progress notes, or care planning in the EHR, despite facility policy and physician orders. Staff interviews confirmed the lack of follow-up and documentation for the resident's condition.
Two residents receiving enteral feeding did not receive proper care as required by facility policy: one resident's intake and output were not monitored or documented, and another resident's enteral feeding formula and water bag were not changed or labeled according to protocol. Staff interviews and record reviews confirmed these lapses in care and documentation.
The facility did not ensure proper respiratory care for four residents, including failure to administer oxygen as ordered, improper storage of nasal cannula tubing, lack of care planning and maintenance for a CPAP device, and oxygen tubing left on the floor. Staff did not consistently follow physician orders or infection control policies, and there was no documentation of communication with physicians regarding changes in respiratory care.
A resident did not receive appropriate pain management when staff failed to accurately document pain assessments and administered oxycodone outside of the prescribed pain level parameters. Non-pharmacological interventions were not consistently implemented or documented prior to medication administration, and staff interviews confirmed these lapses in following physician orders and facility policy.
Two residents with ESRD did not receive appropriate dialysis care, as the facility failed to complete dialysis communication records, maintain an emergency dialysis kit at the bedside, and ensure licensed nurses assessed and documented dialysis access sites or maintained transparent dressings. These deficiencies were confirmed by both nursing staff and the DON.
A resident with severe cognitive impairment and a diagnosis of dementia did not receive the required monitoring and documentation of mood and behavioral symptoms as outlined in their care plan. Staff interviews and medical record reviews confirmed that assessments for altered mood and related dementia symptoms were not performed or documented, despite facility policy and care plan directives.
Two residents received controlled medications that were dispensed and signed out, but the administration was not documented on the EMAR as required by facility policy. This lack of documentation was confirmed through medical record review and staff interviews, and involved both pain and anxiety medications.
A resident with hypertension and congestive heart failure was given amlodipine and two diuretics despite physician orders to hold these medications when blood pressure was below specific thresholds. The MAR showed the medications were administered outside of the prescribed parameters, and staff confirmed that reminders about these parameters were present in the MAR.
Surveyors found that medications were not properly stored or labeled, with oral and external medications mixed in medication carts, a topical antibiotic missing an open date, and two residents' creams stored at the bedside without proper orders or documentation. Staff confirmed these practices did not follow facility policy.
Surveyors observed that hot food items, including meats, vegetables, and potatoes, were served at temperatures significantly below facility policy requirements. During a test tray evaluation, the Dietary Services Supervisor confirmed that food temperatures ranged from 75.3 to 101 degrees Fahrenheit, which did not meet the standard for hot meal service. Residents had also reported concerns about receiving cold food.
A resident with severe cognitive impairment and under hospice care for cerebral infarction did not receive scheduled hospice aide visits as required by the hospice provider's calendar. Documentation and interviews confirmed that multiple visits were missed and there was no communication from the hospice provider regarding these changes, contrary to facility policy and contractual obligations.
The facility failed to ensure proper assessment, documentation, and communication of care for three residents: one resident's foot conditions were not addressed or documented as recommended by a podiatrist; another resident did not receive complete post-fall neurological assessments and monitoring; and a third resident was assisted with thickened liquids using a straw instead of a spoon, contrary to hospital discharge instructions, with no evidence these instructions were communicated to the physician.
The facility failed to obtain and document required baseline measurements for PICC and midline catheters, did not label a PIV site with date, time, and nurse initials, and did not secure a physician's order for a PIV, as confirmed by staff interviews and medical record reviews for four residents receiving IV therapy.
The facility's assessment was not developed with active involvement from direct care staff, residents, or their representatives, and failed to address necessary staffing resources for weekends, recruitment and retention strategies, or a contingency plan for staffing needs, as confirmed by the Administrator.
Three resident rooms were found with environmental deficiencies, including a rusted and soiled vent cover, a ceiling hole above a bed, and multiple bed footboards with ripped corners exposing inner materials. These issues were confirmed by the Maintenance Director and IP during facility observations.
The facility did not ensure that medical records and inventories of personal effects were accurate and complete for several residents. Inventories were missing required signatures from residents' representatives, and POLST forms lacked essential information such as physician contact details and resident or responsible party signatures. The DON confirmed these omissions during record review.
A facility failed to report an allegation of resident-to-resident abuse involving a resident who was verbally abusive and threatening towards their roommate. The incident was not reported to the CDPH, L&C Program, or the local ombudsman, resulting in the allegation going uninvestigated. The facility's Administrator and DON confirmed the failure to report.
A facility failed to investigate a reported incident of verbal abuse by a resident towards their roommate, as required by their abuse P&P. The incident, documented by the SSD, involved a resident threatening their roommate throughout the night, causing fear. Despite the Administrator being informed and contacting the physician, no investigation was conducted, as confirmed by interviews with the DON and Administrator.
A facility failed to obtain informed consent for a resident's use of lorazepam and increased dosage of citalopram, and did not provide non-pharmacological interventions for psychotropic medication use. The resident was on buspirone, citalopram, and quetiapine, with lorazepam as needed. The absence of informed consent and non-pharmacological interventions was confirmed by the LVN and DON.
A resident with a documented fish allergy was served a fish sandwich due to a menu change that was not properly communicated or identified by staff. Despite the facility's policy for tray identification, the nursing staff relied on an incorrect dinner slip, leading to the resident experiencing an allergic reaction and requiring hospital transfer.
The facility failed to maintain sanitary conditions in a shared bathroom and a dirty laundry bin. Used washcloths and an unlabeled pitcher were found in a shared bathroom, posing a risk of accidental use by residents. Additionally, a CNA was observed handling a dirty laundry bin with bare hands, which had a brown residue suspected to be a bowel movement stain. The DON acknowledged the need for cleaning and glove use to prevent infection spread.
The facility failed to provide timely care and conduct required assessments for two residents. One resident experienced multiple falls without proper assessment or care plan updates, and ordered lab tests were not performed. Another resident did not receive ordered neuro checks after an unwitnessed fall. These deficiencies highlight lapses in following protocols and ensuring resident safety.
Two residents in an LTC facility were prescribed psychotropic medications without appropriate diagnoses. One resident received lorazepam PRN for anxiety without a documented diagnosis, and the medication was renewed beyond 14 days without evaluation. Another resident was given risperidone for psychosis without a documented diagnosis. Observations noted both residents were at risk of falls and exhibited aggressive behavior.
A resident did not receive prescribed medications, including Senna, enoxaparin, acetaminophen, gabapentin, and nystatin, as per physician's orders. The medications were not documented in the MAR, and the resident experienced increased pain, requiring stronger medication. Interviews with the DON and LVNs confirmed the lack of documentation and administration.
A resident experienced a decline in health, including a productive cough, poor meal intake, and refusal of medications. The resident's oxygen saturation dropped to 81%, but this was not communicated to the charge nurse. The resident was later found unresponsive, leading to emergency intervention. The facility failed to initiate a care plan or monitor the resident's condition as required.
The facility failed to prevent and manage pressure ulcers for two residents. One resident was not repositioned every two hours as required, while another resident's pressure ulcer was not assessed weekly, leading to worsening conditions. Staff interviews confirmed these deficiencies, highlighting a lack of adherence to care plans and assessment schedules.
The facility failed to follow Enhanced Barrier Precautions (EBP) for a resident, as staff did not wear gowns during high-contact care activities, including wound care. Additionally, hand hygiene was not performed between glove changes, and unused medical supplies were improperly handled, increasing the risk of infection spread.
A resident with intact cognition and limited range of motion had their call light blinking for an extended period without response from RN 1, who passed by twice. The call light was eventually answered by the Activity Director, who assisted the resident with marking her clothes.
A facility failed to maintain accurate medical records for a resident, including discrepancies in oxygen saturation documentation and oxygen administration orders. The resident's POLST form lacked proper signatures and advance directives were not documented in the medical record. Interviews with staff confirmed these deficiencies.
A facility failed to report an alleged staff-to-resident abuse incident to the appropriate authorities, as required by policy and federal regulations. The incident involved a resident with moderate cognitive impairment who expressed fear of a male CNA. Despite being reported internally, the incident was not documented or reported to external agencies.
The facility failed to conduct a comprehensive investigation into an alleged abuse incident involving a resident with hemiplegia and hemiparesis. Despite reports from a family member and the Activity Director, only the alleged perpetrator was interviewed, and the incident was not documented, violating the facility's abuse policy and procedure.
A facility failed to provide necessary foot care services for a resident with severe cognitive impairment and Type 2 Diabetes Mellitus. After receiving podiatry care for a fungal infection, the facility did not ensure proper skin checks, assessments, or monitoring of the resident's feet. No care plan was developed for the fungal infection, and a subsequent change in the resident's condition led to hospitalization. The DON confirmed the lack of documentation for monitoring and care planning.
A facility failed to provide non-pharmacological interventions for a resident prescribed Lexapro for depression, despite multiple episodes of tearfulness. The facility's policy requires minimizing medication use through non-pharmacological approaches, but no such interventions were documented or included in the care plan. The DON confirmed the lack of documentation for these interventions.
The facility failed to prevent and manage pressure injuries for three residents by not conducting weekly wound assessments and improperly setting low air loss mattresses. A resident's pressure injuries were not measured or photographed weekly, and their mattress was set too firm for their weight. Two other residents also had mattresses set too firm, increasing the risk of pressure injuries. The DON acknowledged these deficiencies.
The facility failed to maintain its infection control program, as evidenced by staff not wearing disposable gowns during wound care and resident transfers, and not establishing clean fields for wound supplies. These lapses involved two residents with wounds and indwelling devices, posing a risk of infection spread.
Failure to Provide Ordered CPR, Diagnostic Follow-Up, Lab Response, and Wound Care
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders, facility policies, and residents’ needs and conditions. For one resident with a documented full code status and POLST indicating CPR and full treatment, staff initiated CPR after the resident was found unresponsive, pulseless, and not breathing. Staff reported that after approximately 18–20 minutes of CPR, a carotid pulse was obtained, but the resident remained unconscious, barely breathing, and without a blood pressure reading. Despite this, staff stopped chest compressions and rescue breathing while waiting approximately 5–7 minutes for paramedics to arrive. When the fire department arrived, they found the resident pulseless, apneic, and without compressions being performed, and they restarted manual compressions and advanced resuscitation efforts. The facility’s DON stated the expectation was that licensed nurses continue CPR until the fire department arrives and takes over. Another deficiency concerns a resident with severe cognitive impairment who experienced a fall and developed consistent right hip pain with a positive test noted by PT. The PT documented a recommendation for right hip/femur and knee x-rays, but the medical record did not show that nursing staff notified the physician of this recommendation at that time. A later physician order was written for bilateral hip/femur to knee x-rays, but the record only contained results for bilateral hip x-rays and no results for femur-to-knee imaging as ordered. The resident was later found at the hospital to have markedly displaced fractures of the distal femur requiring ORIF surgery. For the same resident, a STAT BMP, CBC, and magnesium were ordered, and lab results showed a hemoglobin of 6.3 g/dL, but the record did not show timely physician or family notification of this abnormal result. The resident was transferred to the ER later with low hemoglobin and received a blood transfusion. The resident’s family member reported not being notified of the low hemoglobin until the following day and that transfer to the hospital occurred two days after the low result. Additional deficiencies for this resident involved failure to follow through on a physician recommendation to obtain a urine sample after a change in condition. The family reported lethargy and sediment in the urine, and the physician recommended collecting a urine sample, but the record contained no physician order, no lab requisition, and no urine test result. The resident, who had a suprapubic catheter and was care planned as at risk for catheter-related complications, was later transferred to the hospital and diagnosed with acute kidney injury and catheter-associated UTI. The family member stated the facility resisted transferring the resident to the hospital until the resident was eventually sent. The facility also failed to provide ordered wound and skin treatments for several residents. For one resident with multiple treatment orders for bilateral upper and lower extremity discoloration, a left thumb lesion, MASD with excoriation to the buttocks, and suprapubic catheter site care and monitoring, the Treatment Administration Record and MAR for specific days lacked nurse initials, indicating treatments and monitoring were not completed. The resident’s family member reported the catheter was visibly cloudy and the split gauze dressing was filthy. For another resident with a gastrostomy tube, the TAR showed no nurse initials on a day when the daily order to cleanse the G-tube site and apply dressing should have been completed. For a third resident with mild cognitive impairment and multiple skin and wound treatment orders, including monitoring lower extremity discoloration, treating facial and shin scabs, managing MASD, and caring for surgical incisions and pressure injuries, the TAR lacked nurse initials for several ordered treatments on a specific day. Staffing assignment records showed that on some days there was no signed or assigned treatment nurse for certain stations, and LVN staff confirmed that missing initials indicated treatments were not completed.
Failure to Continue CPR for Full-Code Resident Until EMS Arrival
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff with documented BLS/CPR competencies provided appropriate and continued emergency care to a full-code resident. Facility policies required that all nursing staff meet competency requirements per state law and that staff certified in CPR/BLS initiate and continue CPR for unresponsive individuals without normal breathing unless a DNR order exists or there are obvious signs of irreversible death. The facility’s CPR policy and cited clinical references emphasized that chest compressions are the cornerstone of CPR, that compressions and ventilations should continue in cycles until an AED is available or additional help arrives, and that compressions should only be stopped when the person speaks, moves, or breathes normally or when help takes over. Resident 7 was admitted with orders indicating full code status, including a POLST specifying “Attempt Resuscitation/CPR” and “Full Treatment” as the primary goal. On the date of the event, documentation in the resident’s eInteract SBAR and progress notes showed the resident was found on the floor next to the bed, unresponsive to verbal and tactile stimuli, with asystole and absence of respirations. CPR was initiated and 911 was called. The notes indicated that after approximately 20 minutes of CPR, return of spontaneous circulation was achieved and care was assumed, and that the fire department arrived and continued CPR and lifesaving measures for another 20 minutes. The resident’s medical record did not contain documentation of vital signs at the time staff believed spontaneous circulation had been achieved. The fire department’s electronic patient care report documented that responders arrived to find the resident on the ground, pulseless, apneic, and without compressions being performed, and that manual compressions were then initiated, BVM with high-flow oxygen was administered, and defibrillation pads were applied, with the rhythm noted as PEA. The emergency department record later documented that the resident died in the ED. In interviews, the Fire Captain stated that staff reported they had provided CPR for about 20 minutes, believed the heart rate had returned, and stopped compressions while waiting for paramedics. In interviews with facility staff, LVN 4 stated the resident was unresponsive with no pulse, and that CPR was started immediately, with LVN 5 performing compressions and RN 3 providing ventilations via Ambu bag. LVN 4 reported that after about 20 minutes of CPR, the resident’s pulse returned and RN 3 instructed staff to stop CPR while waiting for paramedics. RN 3 stated that she and LVN 5 initiated CPR when they found the resident unresponsive and pulseless, with LVN 5 doing compressions and RN 3 providing breaths, and that a pulse was achieved before the fire department arrived; however, she also stated the resident had no blood pressure and remained unconscious. LVN 5 reported finding the resident on the floor, with no pulse oximeter reading, and that RN 3 confirmed no pulse or respirations; he described performing compressions while RN 3 provided breaths, then stopping compressions after 18–20 minutes when a carotid pulse was obtained, even though the resident remained unconscious, was barely breathing, and had no blood pressure for approximately 5–7 minutes while they waited for paramedics. Review of staff records showed that LVN 4 and LVN 5 had documented competencies for emergency equipment and current BLS Provider certification, and RN 3 had documented competencies in emergency equipment, emergency responses, and CPR, along with an RQI Healthcare Provider BLS certificate demonstrating competence in high-quality CPR skills. Despite these documented competencies and the facility’s CPR policy, LVNs 4 and 5 and RN 3 did not continue life-saving measures for the resident, as they stopped chest compressions while the resident remained unconscious, barely breathing, and without a blood pressure reading, and before EMS personnel arrived and took over resuscitation. The facility acknowledged through the DON’s interview that the expectation was for licensed nurses to continue CPR until the fire department arrived and assumed care.
Failure to Notify State LTC Ombudsman of Resident Transfer/Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide the Office of the State LTC Ombudsman with a copy of a required notice of transfer/discharge for one sampled resident. The resident was admitted to the facility and later transferred to an acute care hospital. During a closed medical record review initiated on 12/23/25, surveyors found no documented evidence that the LTC Ombudsman had been notified of this transfer. Review of the resident’s electronic medical record did not contain a completed Notification of Transfer/Discharge form or any documentation indicating that the Ombudsman had been informed of the transfer to the hospital. In an interview and concurrent record review on 1/8/26, RN 3 explained that a change of condition form, transfer form, and notice of transfer were required when transferring a resident and confirmed that all resident information was maintained in the electronic medical record. When asked to locate the Notification of Transfer/Discharge for this resident, RN 3 verified that no such notice had been completed and that there was no documentation of Ombudsman notification. In a subsequent interview on 1/12/26, RN 2, acting as interim DON, acknowledged that facility staff should have completed the resident’s notice of transfer and sent a copy to the LTC Ombudsman.
Failure to Follow Elopement Care Plan for Resident Lacking Capacity
Penalty
Summary
The facility failed to implement and follow the individualized care plan for a resident who lacked capacity to make medical decisions and had a history of mild, intermittent confusion. The resident's care plan, initiated due to elopement risk, specified that the resident was not to leave the facility without being accompanied by a responsible person. Despite this, the resident was allowed to leave the facility for an outpatient medical appointment without accompaniment from a responsible party or the resident's responsible person, as required by the care plan and physician orders. Medical records indicated that the resident left the facility under approved authorization for an appointment but did not return directly afterward, instead going to his apartment before eventually returning to the facility. Documentation did not show that the responsible party was informed or present, and the responsible party later confirmed she was not notified of the appointment or the need to accompany the resident. The DON verified that the care plan was not followed and that the responsible party was not informed, resulting in the resident leaving unaccompanied and eloping after the appointment.
Failure to Administer and Document IV Fluids per Policy
Penalty
Summary
The facility failed to provide necessary treatment and services related to the administration and documentation of intravenous fluids (IVF) for one resident. According to the facility's policy and procedure (P&P) for intravenous administration, staff are required to monitor residents receiving continuous fluids for signs of complications, document specific details of the infusion, and notify the provider of any issues. For the resident in question, a physician's order was received for STAT labs and normal saline IVF at a specified rate. Although a nurse documented that the orders were noted and carried out, there was no evidence in the resident's progress notes or medication administration record (MAR) that the IVF was actually administered or that the IV site was monitored as required. Additionally, there was no documentation that the physician was notified if the IVF was not given. Further review revealed that the required physician's order for the IVF was missing from the resident's order summary and MAR. Interviews with nursing staff confirmed the lack of documentation regarding the insertion of the IV, administration of fluids, and monitoring of the IV site. There was also no record of the removal of the normal saline IVF from the facility's emergency kit, as required by protocol. Both the facility's administrator and director of nursing acknowledged these findings, and the pharmacy supplying the IV fluids confirmed that no documentation was provided by facility staff to show the IVF was removed from the emergency kit for the resident.
Unauthorized Medication Storage at Bedside Without Physician Order
Penalty
Summary
A deficiency occurred when a tube of diclofenac sodium 1% topical gel, which had expired, was found stored at the bedside of a resident who lacked the capacity to understand and make decisions. The medication was not authorized for self-administration, and there was no physician's order, care plan, or documentation permitting the resident to store or self-administer the medication. The facility's policy required that any medications found at the bedside without authorization for self-administration be turned over to the nurse in charge, but this procedure was not followed in this instance. The resident's medical record indicated that the resident did not wish to self-administer medications and had no assessment or order allowing for self-administration. Facility staff, including an RN and the DON, confirmed that the medication should not have been left at the bedside and that it may have been brought in by the resident's family. The medication was accessible in the resident's room, and staff verified that there was no documentation or physician's order supporting its presence or use at the bedside.
Failure to Complete Stat Laboratory Orders as Prescribed
Penalty
Summary
The facility failed to ensure that a physician's order for stat laboratory tests, specifically a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP), was completed for one resident. The physician ordered these tests on 9/5/25 at 1315 hours due to the resident's decreased urine output and increased lethargy. However, a review of the resident's medical record did not show any documented evidence that the stat laboratory tests were performed as ordered. Interviews with nursing staff revealed that stat laboratory orders should be processed as soon as possible, typically within two to four hours, and require both entry into the facility's electronic system and direct communication with the laboratory. The laboratory's records confirmed that no stat order was received for the resident, and the last blood work on file was from a previous date. Further interviews with staff indicated that the expected protocol for stat laboratory orders includes notifying the laboratory by phone, documenting follow-up actions, and informing the physician if there are delays. In this case, the nurse who received the order did not see the laboratory technician arrive before the end of the shift, and there was no documentation of follow-up or communication regarding the delay. The Director of Nursing and Administrator acknowledged these findings during the survey.
Incomplete Documentation of Urine Monitoring for Catheterized Resident
Penalty
Summary
The facility failed to ensure that the medical record for one of six sampled residents was complete, specifically regarding documentation of urine characteristics for a resident with an indwelling urinary catheter. According to the facility's policy and procedure for catheter care, information such as urine color, clarity, and odor should be recorded in the resident's medical record to prevent catheter-associated complications. Medical record review revealed that the Treatment Administration Record (TAR) for August was incomplete, with missing documentation on two shifts where monitoring of urine characteristics was required by physician order. Interviews with two LVNs confirmed that the TAR entries for the specified dates and shifts were left blank, indicating that documentation was not completed. Both LVNs acknowledged that monitoring may have been performed but was not recorded as required. The Director of Nursing stated that the expectation was for licensed nurses to follow physician orders, and both the Administrator and DON acknowledged the findings during the survey.
Incomplete and Inaccurate POLST Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that medical records, specifically the Physician Orders for Life-Sustaining Treatment (POLST) forms, were accurate and complete for three of eight sampled residents. For one resident with dementia and moderate cognitive impairment, the POLST form was missing the physician's phone number, license number, signature, and the responsible party's signature, address, and telephone number. The responsible party's signature was entered by a nurse without indicating it was a verbal consent, and the nurse practitioner’s name was incorrectly entered in the section for the supervising physician. These omissions were verified during a medical record review with a registered nurse. For another resident with moderate cognitive impairment, the POLST form lacked the nurse practitioner's phone number, license number, date signed, and the supervising physician's name. The form also did not indicate whether the information was discussed with the resident, and the resident's address, telephone number, and signature date were missing. A third resident, who was cognitively intact, had a POLST form that did not document a second nurse witnessing the verbal consent from the responsible party, omitted the resident's wishes regarding artificially administered nutrition, and left the responsible party's address and phone number blank. These findings were confirmed by both a registered nurse and the Director of Nursing.
Widespread Kitchen Sanitation and Equipment Failures
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food safety and sanitation. The kitchen hood over the stove was found to have black, greasy residue, despite facility policy requiring it to be cleaned every two weeks and kept free of dust and grease. The Dietary Services Supervisor (DSS) confirmed that the hood was only cleaned once a week and acknowledged the presence of dirt and grease. Additionally, several kitchen utensils, including spatulas, ladles, whisks, and dough cutters, were observed to be chipped, cracked, melted, discolored, or otherwise worn out, contrary to facility policy and USDA Food Code requirements that utensils be maintained in good repair and have smooth, cleanable surfaces. Further observations revealed that numerous kitchen utensils and equipment were not properly cleaned. Items such as ladles, spoons, cake slicers, spatulas, scoops, measuring cups, and dough cutters were found with dry, crusted food residue, watermarks, and bristle-like debris. The DSS acknowledged that these items should have been cleaned and washed to prevent bacteria growth. Cutting boards used for food preparation were heavily marred, fuzzy, and had deep grooves, making them difficult to clean and sanitize. The DSS confirmed that these cutting boards should have been replaced. Additional deficiencies included improper drying and storage of kitchenware. A heavy-duty blender, several ladles, scoops, and clear plastic bins were stored while still wet, and some scoops were also dirty with food residue. The DSS acknowledged that all utensils and equipment should have been air dried before storage. The countertop-mounted can opener and the microwave were both found to have yellowish discoloration resembling rust, with the microwave also having white residue inside the door. The DSS confirmed that these items were old, unsanitary, and needed replacement. These findings were observed during an initial kitchen tour, and the DSS verified all deficiencies.
Infection Control Deficiencies and Failure to Follow Protocols
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices as outlined in its own policies and procedures. Surveyors found that the monthly Infection Prevention and Control Surveillance Logs for January and February did not accurately match the Infection Control Monthly Summary reports, resulting in inaccurate reporting of healthcare-associated infections (HAIs) and community-acquired infections (CAIs). The Infection Preventionist (IP) confirmed that the discrepancies were due to the volume of infections and acknowledged that the numbers should have matched to provide accurate information for infection control monitoring. Additionally, the facility did not follow Enhanced Barrier Precautions (EBP) for a resident with a central line, as there was no signage or personal protective equipment (PPE) available at the doorway, and no physician's order for EBP was documented. Staff also failed to adhere to hand hygiene protocols during resident care activities. For example, an occupational therapist did not perform hand hygiene between assisting multiple residents during mealtime, and a licensed vocational nurse (LVN) did not don a gown when providing enteral feeding care to a resident on EBP. Another LVN failed to perform hand hygiene and change gloves prior to administering insulin to a resident, despite facility policy requiring these steps to prevent infection. Furthermore, improper hand hygiene was observed during wound care treatment for a resident with stage 4 pressure injuries. The LVN performing the wound care did not sanitize hands immediately after removing gloves throughout the procedure, only washing hands at the end of the treatment. These failures were acknowledged by the staff involved and confirmed by the IP and Director of Nursing (DON) during interviews, demonstrating a lack of consistent adherence to infection control protocols designed to prevent the development and transmission of diseases and infections within the facility.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident was found to be self-administering Systane eye drops, despite not being assessed as able or willing to self-administer medications. During an observation, two bottles of Systane eye drops were found on the resident's bedside table, and the resident confirmed self-administration. A licensed vocational nurse (LVN) verified the presence of the medication at the bedside and stated that the resident was not able to self-administer the eye drops and should not have had them at the bedside. Review of the resident's medical record showed no physician's order for the Systane eye drops or for self-administration, and the care plan did not address the resident's eye condition or ability to self-administer medication. The facility's policy requires an assessment, physician's order, and care plan documentation for self-administration, none of which were present for this resident. The Director of Nursing (DON) confirmed that the necessary documentation and orders were missing.
Failure to Maintain and Provide Advance Directive Documentation and Information
Penalty
Summary
The facility failed to obtain and/or maintain copies of advance directives and provide written information regarding the formulation of advance directives for four residents. For two residents who had executed advance directives, the facility did not ensure that copies of these documents were available in their medical records or electronic health records. Interviews with nursing and social services staff confirmed that there was no documented follow-up to obtain these documents, despite facility policy requiring such actions and quarterly checks. For another resident who had not executed an advance directive, the facility did not provide written information or assistance on how to formulate one to the resident or their responsible party. Medical record review and staff interviews confirmed the absence of documentation showing that the required information and assistance were offered, as outlined in facility policy. The responsible staff acknowledged that this step was missed during the admission process and subsequent follow-up. A fourth resident, who lacked decision-making capacity, also did not have documentation in the medical record that the responsible party was provided with information on how to formulate an advance directive. The social services director and DON confirmed that, according to policy, this information should have been offered and documented, but there was no evidence of this in the resident's records. These failures were verified through interviews and concurrent record reviews with facility staff and administration.
Failure to Follow Proper Insulin Administration Procedure
Penalty
Summary
LVN 1 failed to follow the facility's policy and procedure for insulin administration for one resident. During a medication administration observation, LVN 1 was seen wiping the resident's left upper abdominal area with an alcohol wipe and immediately injecting Lantus insulin while the area was still visibly wet. The facility's policy, as well as the manufacturer's administration guide, require that the injection site be cleaned with alcohol and allowed to air dry before injection. LVN 1 did not wait for the alcohol to dry before administering the insulin. Interviews with LVN 1 and the Director of Staff Development (DSD) confirmed that LVN 1 had been trained to allow the injection site to air dry after cleaning with alcohol. Both LVN 1 and the DSD acknowledged that injecting insulin into a site that is still wet with alcohol could cause stinging and potentially alter the effect of the medication. The deficiency was identified through observation, interview, and review of facility policies and training records.
Failure to Document and Assess Skin During Splint Use for Resident with Limited ROM
Penalty
Summary
The facility failed to follow a physician's order for the application of a left knee extension splint for a resident with limited range of motion (ROM). The order specified that the splint should be applied to the resident's left knee five times a week for up to five hours a day or as tolerated. However, there was no documentation of the exact times when the splint was applied and removed. Additionally, the care plan and medical record did not include or document any skin assessments when the splint was in use, despite the resident having hardware (screws) in the leg and being at risk for skin issues. Interviews with staff confirmed that while the splint was applied as ordered, there was no record of skin assessments being performed or documented during its use. The facility's policy on restorative nursing services required care to promote safety and independence, but the lack of documentation and omission of skin assessments represented a failure to provide appropriate care to prevent a decline in ROM and potential skin complications. The Director of Nursing verified these findings during the survey.
Failure to Document and Respond to Change in Condition for Catheterized Resident
Penalty
Summary
A deficiency occurred when a resident with an indwelling urinary catheter did not receive appropriate care and services as required by facility policy and physician orders. The resident, who had moderate cognitive impairment, was observed on multiple occasions with cloudy urine and sediments in the catheter tubing. Despite these findings, which were recognized by nursing staff as a change in condition and potential sign of infection, there was no documentation of a change of condition (COC) assessment, progress notes, or care plan in the resident's electronic health record (EHR) for several days. Interviews with licensed nursing staff confirmed that the facility's policy required immediate reporting and documentation of unusual findings such as cloudy urine with sediments. However, staff acknowledged that no COC documentation, progress notes, or care plan had been completed for the resident's condition during the relevant period. One nurse stated that the change was reported to other staff, but those staff members did not follow up with the required documentation or care planning. The administrator was informed and acknowledged these findings.
Failure to Monitor and Document Enteral Feeding Care and Adherence to Protocols
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for two residents receiving enteral feeding. For one resident, staff did not monitor or document intake and output as required by both the resident's care plan and the facility's policy. The resident had a history of dysphagia and was receiving Glucerna via GT at a prescribed rate. Despite a care plan intervention to monitor intake and output, there was no evidence in the medical record that this was being done. Interviews with staff, including an LVN and the DON, confirmed that intake and output monitoring was not consistently performed or documented for residents on tube feeding, contrary to facility protocol and care plan requirements. For another resident, the facility did not ensure that the enteral feeding formula was changed within 24 hours, nor was the formula bottle properly labeled with the start time and nurse's initials. Additionally, the water bag used for enteral feeding was not labeled with the date and time it was prepared. This resident also had a history of dysphagia and was receiving Jevity 1.2 via feeding pump, along with scheduled water flushes. Observation and interviews confirmed that the labeling and timely changing of the formula and water bag were not performed as required by facility policy. These deficiencies were identified through observation, interviews, medical record review, and review of facility policies and procedures. Both the DON and Administrator acknowledged the findings related to the lack of intake and output monitoring, as well as the failure to follow protocols for changing and labeling enteral feeding supplies.
Failure to Provide Safe and Appropriate Respiratory Care and Maintain Infection Control
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents who required oxygen therapy or CPAP support. For two residents, staff did not ensure oxygen was administered as per physician orders and failed to store nasal cannula tubing in a sanitary manner. One resident was observed with a nasal cannula left on the bed and not in a plastic bag, while another had the tubing wrapped around a bed rail. In both cases, the oxygen concentrator was running, but the residents were not using the oxygen as ordered, and there was no documentation of communication with the physician regarding changes in oxygen use or need. Another resident using a CPAP machine did not have a care plan addressing the use of the device, and there was no physician's order for the cleaning and maintenance of the CPAP as directed by the manufacturer's guidelines. The CPAP mask was left on top of a drawer, and the tubing was stored in a plastic bag, but staff could not provide the user guide for the device and confirmed that cleaning instructions were not being followed or documented. Additionally, a resident receiving continuous oxygen therapy was observed with oxygen tubing touching the floor, which was verified by the infection preventionist. The facility's policies required proper storage and regular changing of oxygen tubing and cannulas, as well as adherence to infection control practices, but these were not consistently followed for the residents reviewed.
Failure to Provide and Document Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for one resident by not accurately documenting pain assessments and not administering pain medication according to the physician's orders. Specifically, the medical record review showed that the resident was given oxycodone, a narcotic opioid, even when the documented pain level was zero, which was outside the ordered parameters that required administration only for moderate to severe pain (pain levels 6-10). Additionally, pain assessments were not consistently documented each shift as required, and there were discrepancies between the administration of pain medication and the recorded pain levels. The facility also did not ensure that non-pharmacological interventions were implemented and documented prior to administering pain medication, as required by both physician orders and facility policy. On several occasions, the non-pharmacological interventions were either not documented or were marked as 'none' before the administration of oxycodone. This was confirmed through review of the Medication Administration Record (MAR) and interviews with both the LVN and the DON, who acknowledged that non-pharmacological interventions should have been attempted and documented prior to medication administration. Interviews with facility staff, including the LVN and DON, confirmed that the expected process was not followed. Both staff members verified that pain medication should not be administered when the pain level is documented as zero, and that non-pharmacological interventions should not be marked as 'none' if pain medication is given. The DON also stated that pain assessments should be accurately documented each shift and updated if the resident's pain status changes after initial documentation.
Failure to Provide Safe and Appropriate Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide appropriate dialysis care for two residents with end-stage renal disease (ESRD) who required dialysis services. For one resident, the dialysis communication records, which serve as a communication tool between the dialysis center and the facility, contained multiple blank entries for the dialysis access site assessment on several dates. Both the LVN and the DON confirmed that these records should have been fully completed prior to the resident going to the dialysis center, as per facility policy. For another resident, the facility did not ensure that an emergency dialysis kit was kept at the bedside, as required by physician's order and facility policy. During an interview and observation, the LVN was unable to locate the emergency dialysis kit at the resident's bedside, despite acknowledging that it should be present even if the resident was no longer receiving dialysis treatments but still had a dialysis access in place. The DON also confirmed that the kit should have been readily available for any resident with a dialysis access. Additionally, the facility failed to ensure that licensed nurses assessed and documented the resident's dialysis access site and maintained a transparent dressing over the site. Medical record review showed no documentation of assessment of the dialysis catheter, and the resident's care plan did not address the care of the dialysis catheter. Observation confirmed that the resident's dialysis access site was not covered with a transparent dressing, and the DON was unable to find documentation of the last dressing change. These failures were verified by both the LVN and the DON during interviews and record reviews.
Failure to Implement and Document Dementia Care Interventions
Penalty
Summary
The facility failed to implement and document dementia care interventions for one resident diagnosed with dementia. According to the facility's own policy, staff and physicians are required to evaluate, monitor, and document the cognitive and behavioral status of residents with dementia, including signs of altered mood, loss of interest in activities, and other related symptoms. For the resident in question, the care plan specifically called for monitoring and reporting of mood changes and symptoms of depression or anxiety. However, medical record review revealed no documented evidence that these assessments or monitoring activities were being performed as required. Observations and interviews with staff confirmed that the resident exhibited severe cognitive impairment, was dependent for most ADLs, and displayed behaviors such as confusion, aggression, and lack of interaction. Despite these symptoms and the care plan directives, both CNAs and LVNs were unable to provide documentation of behavior or mood monitoring for the resident. The DON also verified that no such documentation existed, confirming that the required interventions and monitoring for dementia-related symptoms were not being carried out as outlined in the resident's plan of care.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to provide necessary pharmaceutical services in accordance with its policies and procedures for two residents. For one resident with the capacity to make decisions, a physician's order was in place for oxycodone-acetaminophen to be administered as needed for moderate to severe pain. The medication was dispensed and signed out, but there was no documentation of its administration on the Medication Administration Record (MAR) for the specified date and time. This omission was verified during a medical record review and interview with a registered nurse. Similarly, for another resident who was unable to make decisions, a physician's order was in place for lorazepam to be administered as needed for anxiety. The medication was dispensed and signed out, but again, there was no documentation of its administration on the MAR for the specified date and time. This finding was also confirmed through medical record review and staff interviews. The facility's policies require that the administration of controlled substances be documented on the MAR, including the date, time, dosage, route, and the signature of the administering nurse, which was not followed in these instances.
Failure to Adhere to Blood Pressure Parameters for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not adhering to physician-prescribed blood pressure parameters for three medications: amlodipine, spironolactone, and ethacrynic acid. The physician’s orders specified that amlodipine should be held if the systolic blood pressure was less than 115 mmHg or the heart rate was less than 56 bpm, and that both diuretics should be held if the systolic blood pressure was less than 110 mmHg or the heart rate was less than 60 bpm. Despite these parameters, the resident was administered amlodipine when their systolic blood pressure was 113 mmHg and both diuretics when their systolic blood pressure was 104 mmHg, as documented in the Medication Administration Records (MAR) for January and March. The resident had a history of hypertension and congestive heart failure and was determined to have the capacity to understand and make decisions. During interviews, the LVN confirmed that reminders regarding medication parameters were present on the MAR prior to administration, and both the DON and Administrator acknowledged the findings. The facility’s policy required medications to be administered in accordance with prescribed orders, but this was not followed in the instances identified.
Deficiencies in Medication Storage, Labeling, and Documentation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication management practices. During inspections of two medication carts, it was observed that orally administered medications were not stored separately from externally used medications, such as ointments, creams, and eye drops, contrary to facility policy. Staff, including the ADON and an RN, verified these findings. Additionally, a gentamicin ointment used for a resident's skin infection was found without an open date on its label, which was confirmed by both the LVN and the DON as a requirement for proper labeling. Further review revealed that a resident's Preparation H and Lidocaine creams were stored at the bedside without a physician's order or care plan authorizing bedside storage. The LVN responsible for administering these medications admitted to storing them at the bedside and failing to document their administration on the Treatment Administration Record (TAR) for several days. The DON and Administrator acknowledged these findings during interviews. The report also notes that the resident had the capacity to make decisions, as documented in their medical record.
Failure to Serve Hot Food at Required Temperatures
Penalty
Summary
Surveyors found that the facility failed to serve food items at appetizing and safe temperatures, as required by facility policy and best practices. During a meal service observation, residents expressed concerns that hot food items were being served cold. A review of the facility's policies indicated that hot foods, including meats, vegetables, and potatoes, should be served at or above 140 degrees Fahrenheit, with specific service temperatures for certain items ranging from 160-180 degrees Fahrenheit, and a minimum delivery temperature of 120 degrees Fahrenheit for hot entrees, starches, and vegetables. On the day of the survey, a test tray was evaluated in the presence of the Dietary Services Supervisor (DSS) and surveyors. The measured temperatures of various hot food items, including roast turkey, vegetables, and potatoes, ranged from 75.3 to 101 degrees Fahrenheit, all of which were below the recommended serving temperatures. The DSS confirmed that these temperatures did not meet the facility's standards for hot food service and acknowledged that the food was not hot as required. This failure affected the majority of residents who consumed meals prepared in the kitchen.
Failure to Provide Scheduled Hospice Aide Visits and Communication
Penalty
Summary
The facility failed to ensure that a resident receiving hospice care was provided with the scheduled hospice aide (HA) visits as outlined by the hospice provider's calendar. According to the medical record and hospice documentation, the resident was to receive HA visits every Tuesday and Thursday, but there were no documented visits on 3/25, 3/27, 4/1, and 4/3, with the last recorded visit occurring on 3/20. Interviews with facility staff, the resident's family member, and hospice personnel confirmed that the scheduled visits did not occur and that there was no communication from the hospice provider regarding changes to the visit schedule. The resident in question had severe cognitive impairment, as indicated by a BIMS score of three, and was under hospice care for a cerebral infarction. Facility policy and the hospice contract required timely delivery of hospice services and communication between the hospice provider, facility staff, and the resident's family. However, the lack of scheduled HA visits and absence of communication about missed visits demonstrated a failure to provide necessary care and services as required by both facility policy and the hospice agreement.
Failure to Provide and Document Appropriate Care and Services
Penalty
Summary
The facility failed to provide necessary care and services to three residents, resulting in deficiencies related to assessment, documentation, and communication of care needs. For one resident, a black scab under the second right toenail and dryness on both feet were observed, but these conditions were not addressed in the comprehensive skin assessment. Although a podiatry visit had recommended applying lotion to restore moisture, the wound care nurse was unaware of these additional foot conditions, and there was no documentation that the recommendations were followed. Another resident experienced a fall, and the facility did not complete or accurately document the required post-fall neurological assessments and monitoring. Several neurological assessment components, such as pupil response, extremity motor function, and pain response, were missing or not completed at multiple required intervals. Additionally, progress notes did not reflect post-fall monitoring during several shifts, contrary to facility policy that mandates such monitoring every shift for 72 hours post-fall. A third resident, who had specific swallowing and diet recommendations from an acute care hospital, was observed being assisted with thickened liquids using a straw, despite discharge instructions specifying that liquids should be given by spoon only. There was no evidence that these recommendations were communicated to the attending physician or incorporated into the resident's care plan. Staff interviews confirmed the lack of documentation and awareness regarding the required feeding method.
Failure to Document and Monitor IV Line Care and Orders
Penalty
Summary
The facility failed to provide necessary care and services related to the administration and monitoring of intravenous (IV) lines for four residents. For two residents with peripherally inserted central catheters (PICC lines), baseline external catheter length and arm circumference measurements were not obtained or documented upon admission, as required for proper monitoring. In one case, a resident with a midline catheter did not have arm circumference and external catheter length measured on admission or during dressing changes, despite physician orders specifying these requirements. Documentation of these measurements was also missing from the medical records and IV medication administration records. Additionally, a resident with a peripheral intravenous (PIV) line did not have the site labeled with the date, time, and nurse's initials, and there was no physician's order for the PIV, contrary to facility policy and standard practice. Observations confirmed the absence of labeling and orders, and interviews with nursing staff verified that these steps had not been completed. The lack of documentation and assessment could delay the identification of IV catheter-related complications, as noted in the findings. Medical record reviews and staff interviews consistently revealed that required assessments, documentation, and care planning for IV lines were not performed according to facility policy and physician orders. The Director of Nursing (DON), Assistant Director of Nursing (ADON), and other nursing staff acknowledged these deficiencies during interviews and record reviews. The failures were observed across multiple residents and types of IV access, including PICC lines, midlines, and PIVs.
Facility Assessment Lacks Required Input and Staffing Plans
Penalty
Summary
The facility failed to ensure its Facility Assessment was developed with the active involvement of required individuals, including direct care staff, direct care representatives, residents, residents' representatives, and family members. The assessment did not document participation from these groups, as verified by the Administrator during an interview and document review. Additionally, the assessment did not address the resources necessary to care for residents during weekends, nor did it include a plan to maximize recruitment and retention of direct care staff or a contingency plan for staffing needs. The deficiency was identified through a review of the Facility Assessment and confirmed by the Administrator, who acknowledged that the assessment was not updated to reflect the latest CMS guidance. The lack of comprehensive input and planning in the assessment process had the potential to result in unmet care needs for residents, particularly if the facility's population needs and available resources were not fully identified and addressed.
Failure to Maintain Safe and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in three resident rooms. In Room A, a vent cover was found with rust and a black substance around it, and a hole approximately one inch in diameter was observed on the ceiling above a resident's bed. In Room C, the footboard of a resident's bed had ripped corners, exposing the inner cardboard surface. In Room B, the footboards of three residents' beds were also found with ripped corners, exposing the inner cardboard. These conditions were confirmed by the Maintenance Director and the Infection Preventionist during observations and interviews.
Incomplete Medical Records and Personal Effects Inventories
Penalty
Summary
The facility failed to ensure that medical records and inventories of personal effects for four residents were accurate and complete, as required by facility policy and accepted professional standards. Specifically, for three residents, the Inventory of Personal Effects forms were not reviewed with or signed by the residents' representatives upon admission, with signature sections left blank and undated on multiple occasions. The Director of Nursing (DON) confirmed that these inventories were completed by CNAs at admission but acknowledged that the forms should have been fully completed to account for all personal belongings. Additionally, two residents had incomplete Physician Orders for Life-Sustaining Treatment (POLST) forms. The missing information included the physician's telephone number, license number, and the resident's or responsible party's signature, address, and phone number, as well as the date the POLST was completed. The DON verified these omissions and stated that the POLST forms were completed by RNs at admission and followed up by social services staff, but should have been fully filled out as they contain relevant medical information.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure for reporting suspected abuse, neglect, or theft, as required by section 1150B. Specifically, the facility did not report an allegation of resident-to-resident abuse involving Resident 5 to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program, or the local ombudsman. This oversight resulted in the abuse allegation going unreported and uninvestigated. Resident 5, who was admitted to the facility with the capacity to understand and make decisions, was documented as being verbally abusive and threatening towards their roommate on 7/31/24. The situation was brought to the attention of the facility's Administrator, who contacted the physician but failed to report the incident to the appropriate authorities. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the required reporting did not occur.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedure (P&P) related to the investigation of resident-to-resident abuse for one of the sampled residents. Specifically, the facility did not conduct a thorough investigation when Resident 5 was reported to be verbally abusive to their roommate. This incident was documented in a progress note by the Social Services Director (SSD), indicating that Resident 5 was threatening the roommate throughout the night, causing the roommate to feel scared. Although the Administrator was made aware of the situation and contacted the physician, no investigation was initiated. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the facility did not investigate the abuse allegation, which was a requirement according to the facility's P&P revised in September 2022.
Failure to Obtain Informed Consent and Provide Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the facility did not obtain informed consent from the resident or their surrogate decision maker for the use of lorazepam and for an increase in the dosage of citalopram. The resident was on a regimen of buspirone, citalopram, and quetiapine, with lorazepam prescribed as needed. However, there was no documentation of informed consent for the increased dosage of citalopram or the renewed order for lorazepam. Additionally, the facility did not provide or document non-pharmacological interventions for the resident's use of psychotropic medications, as required by the facility's policy. Interviews with the LVN and DON confirmed the absence of informed consent and non-pharmacological interventions. These deficiencies were acknowledged by the facility's administrator.
Failure to Adhere to Resident's Food Allergy Leads to Adverse Reaction
Penalty
Summary
The facility failed to ensure that Resident 4's food allergies were considered and adhered to, resulting in the resident being served food containing fish, to which they were allergic. This incident occurred despite the facility's policy and procedure for tray identification, which mandates the use of appropriate identification to ensure correct diets are served. The dietary services supervisor (DSS) had changed the menu from grilled chicken to breaded fish due to a vendor issue, and this change was communicated to the nursing staff. However, the nursing staff relied on the dinner slip, which incorrectly listed grilled chicken, leading to the resident being served fish. Resident 4, who had a documented allergy to fish, experienced an allergic reaction after consuming the fish sandwich. The resident's medical records and care plan clearly indicated the allergy, and the resident was capable of understanding and making decisions. After taking a bite of the sandwich, the resident experienced symptoms of an allergic reaction, including difficulty breathing and a heavy feeling in the throat. The resident was subsequently transferred to an acute care hospital for treatment. Interviews with facility staff, including the DSS, RN, and DON, revealed that the process for checking meal trays involved comparing the meal ticket with the diet list and visually inspecting the tray. However, the fish was shredded and mixed with other ingredients, making it difficult to identify visually. The failure to correctly identify the sandwich protein as fish, despite the documented allergy, led to the adverse reaction experienced by Resident 4.
Sanitation Deficiencies in Shared Bathroom and Laundry Bin
Penalty
Summary
The facility failed to maintain sanitary environmental conditions, as evidenced by observations in a shared toilet/bathroom and a dirty laundry collection bin. In the shared bathroom for Rooms A and B, several used washcloths were found by the sink, on top of the paper towel dispenser, and hanging on the toilet seat lid. Additionally, a yellow and pink pitcher without a label was observed by the sink. RN 3 acknowledged that the used washcloths should have been collected by the CNA and placed in the dirty linen, and the pitcher should have been labeled and not left in the bathroom. These items posed a risk of being accidentally used by another resident. Furthermore, a dirty laundry collection rolling bin was observed with a brown residue on the top corner, which was touched multiple times with bare hands by a CNA while pushing the bin. The CNA speculated that the residue could be a bowel movement stain from dirty linen and acknowledged that the bin should have been cleaned and gloves should have been worn to prevent the spread of infection. The DON confirmed that the bin should have been cleaned and gloves should have been used to maintain hygiene and prevent infection spread.
Failure to Provide Timely Care and Conduct Required Assessments
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment and well-being. Resident 2 experienced multiple falls, and the facility did not conduct timely assessments or update the care plan to reflect these incidents. On 12/24/24, Resident 2 fell from a wheelchair due to a slipping seat cushion, and although neuro checks were recommended, there was no evidence of a comprehensive assessment or notification to the physician and resident's representative. Another fall occurred on 12/26/24, but the facility did not document the incident properly or update the care plan, as confirmed by the Director of Nursing (DON) and Licensed Vocational Nurse (LVN) 1. Additionally, the facility failed to perform ordered laboratory tests for Resident 2. On 12/24/24, a physician ordered a CBC, CMP, and UA with culture due to a change in condition, but there was no documentation that these tests were completed. The DON was unable to provide evidence that the tests were conducted, indicating a lapse in following physician orders and ensuring necessary diagnostic evaluations. Resident 1 also suffered from inadequate care following an unwitnessed fall on 11/23/24. Despite a physician's order for neuro checks every shift for 72 hours post-fall, there was no documented evidence that these checks were performed. The fall resulted in skin tears, and the resident was sent to an acute care hospital for evaluation. Upon return, the facility did not conduct the required neuro checks, as verified by LVN 2 and the DON. This oversight in monitoring and documentation highlights a failure to adhere to post-fall protocols and ensure resident safety.
Failure to Document Appropriate Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic drugs. Resident 1, diagnosed with dementia, was prescribed lorazepam PRN for anxiety manifested by restlessness without a documented diagnosis of anxiety prior to the medication's initiation. The physician's orders for lorazepam were continuously renewed beyond the standard 14-day period without documented evaluation or rationale from the prescribing practitioner. Observations revealed that Resident 1 was often asleep for extended periods after medication administration, and staff noted the resident's high fall risk and aggressive behavior. Resident 8, also diagnosed with dementia, was prescribed risperidone for psychosis manifested by inconsolable episodes of calling out, despite lacking a documented diagnosis of psychosis prior to the medication's initiation. The facility's records did not provide evidence of a diagnosis of psychosis, and staff were unable to clarify the origin of this diagnosis. Observations indicated that Resident 8 was a fall risk and exhibited wandering and aggressive behavior. The facility's failure to document appropriate diagnoses and evaluations for the use of psychotropic medications placed the residents at risk for receiving unnecessary medications and potential adverse reactions. The lack of documented clinical rationale for extending PRN orders beyond 14 days and the absence of proper diagnoses for the prescribed medications were significant deficiencies identified during the survey.
Failure to Administer and Document Medications
Penalty
Summary
The facility failed to administer necessary medications to a resident as per the physician's orders, which included Senna, enoxaparin, acetaminophen, gabapentin, and nystatin suspension. These medications were not given on a specific date, and there was no documentation in the Medication Administration Record (MAR) to indicate if they were withheld for any reason. The resident, who had an intact cognition with a BIMS score of 14, reported not receiving the enoxaparin injection and other pain medications, which led to increased pain levels, requiring stronger pain medication. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) revealed that the medications were not documented as administered in the MAR. LVN 3 mentioned time constraints as a possible reason for the lack of documentation, while LVN 4 confirmed that there was no report of the resident refusing the medication. The DON acknowledged the failure to document the administration of medications, which was expected to be done as per the facility's policy and procedures.
Failure to Monitor and Communicate Resident's Condition
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained the highest practicable physical well-being. The deficiency involved a resident who was admitted and later readmitted to the facility, and subsequently transferred to an acute care hospital. On a specific date, a family member reported the resident had a productive cough and appeared slightly weak. The following day, the resident's poor meal intake was noted, and several medications were refused by the resident. Despite these observations, there was no care plan initiated for the change in condition, and the resident was not monitored every shift as expected. Additionally, the resident's oxygen saturation level was recorded at a critically low 81%, but this information was not communicated to the charge nurse by the CNA who took the measurement. The charge nurse only became aware of the resident's deteriorating condition when the resident was found unresponsive with abnormal vital signs, prompting a call to emergency services. Interviews with the LVN and CNA involved confirmed the lack of communication and monitoring, and the DON acknowledged the expectation for monitoring and documentation of the resident's condition every shift for at least 72 hours.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of new pressure injuries and promote healing of existing pressure ulcers for two residents. Resident 8 was not turned and repositioned at least every two hours as per the facility's policy and plan of care. Observations on multiple occasions showed Resident 8 lying on her right side for extended periods, contrary to the facility's turning schedule. Interviews with staff confirmed the lack of adherence to the turning schedule, which posed a risk for the development of new pressure ulcers and worsening of existing ones. For Resident 11, the facility failed to conduct weekly assessments of a pressure ulcer on the coccyx, which was initially a Stage 2 ulcer upon admission. The medical record review revealed a lack of a care plan for managing the resident's pressure ulcers, and no assessments were documented between 9/19/24 and 10/11/24. When the ulcer was finally assessed, it had worsened, with the stage being undetermined and significant slough present. Interviews with staff confirmed the lack of timely assessments and the absence of a care plan, which hindered proper intervention for the resident's pressure ulcers.
Infection Control Lapses in EBP for Resident
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for Resident 9. Staff members, including LVN 4 and a wound consultant, did not wear disposable gowns while performing wound care on Resident 9, despite the presence of an EBP sign indicating the requirement for gown and glove use during high-contact care activities. This oversight was confirmed through interviews with the involved staff and the Infection Preventionist (IP), who acknowledged the lapse in following the facility's policy. Additionally, during a wound treatment observation, LVN 5 and CNA 2 did not wear gowns while providing care to Resident 9, who was on EBP. LVN 5 also failed to perform hand hygiene between glove changes during the wound care process. Furthermore, LVN 5 returned unused gauze and a bottle of normal saline to the treatment cart without proper disposal, acknowledging the mistake in an interview. These actions were contrary to the facility's infection control policies and had the potential to contribute to the spread of infections within the facility.
Delayed Response to Call Light for Resident
Penalty
Summary
The facility failed to accommodate the needs of Resident 12, who was part of a sample of 12 residents. Resident 12, who has intact cognition and a limitation in the range of motion on one side of both upper and lower extremities, was observed to have their call light blinking outside Room C for an extended period. Despite the call light being on, RN 1 passed by the room twice without responding, as he was heading to another station. The call light was eventually answered by the Activity Director, who found that Resident 12 needed assistance to mark her clothes. This delay in responding to the call light had the potential to prevent the resident from having her needs met in a timely manner.
Incomplete and Inaccurate Medical Records for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, which could negatively impact the delivery of services. The resident's Medication Administration Record (MAR) for September 2024 indicated that oxygen saturation should be checked each shift. However, on the evening shift of September 28, 2024, the recorded oxygen saturation level was 76%, while it should have been documented as 96% according to the Licensed Vocational Nurse (LVN) interviewed. Additionally, discrepancies were found in the documentation of oxygen administration. The Interact SNF/NF to Hospital Transfer Form indicated the resident was provided with oxygen at 4 LPM, while a late entry nurse's note stated the resident received high flow oxygen at 15 LPM via a non-rebreather mask. There was no physician's order for either 4 LPM or 15 LPM oxygen administration. Furthermore, the facility failed to properly document the resident's advance directives. The resident's POLST form dated June 14, 2024, indicated verbal consent was obtained from a family member but lacked the signature of the resident or a legally recognized decision maker. The POLST form from October 6, 2023, marked no advance directives, and the resident's medical record did not contain any advance directive documentation. Interviews with the LVN, Medical Records Director, and Social Worker confirmed the absence of advance directives in the resident's electronic and paper medical records. The Social Worker noted that the POLST from October 6, 2023, should have been carried forward upon the resident's readmission.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act. This deficiency occurred when the facility did not report an allegation of staff-to-resident abuse involving a certified nursing assistant (CNA) and a resident with moderate cognitive impairment. The incident was initially reported by the Activity Director and a family member to the Director of Nursing (DON) and the Administrator, but no report was made to the California Department of Public Health Licensing and Certification Program, law enforcement, or the Ombudsman office. The alleged abuse was also not documented by the facility. The resident involved, who had a diagnosis of hemiplegia and hemiparesis affecting the right side, expressed fear and distress when recounting the incident. The resident indicated that a male staff member had been abusive, which was corroborated by the family member who identified the CNA when the resident showed signs of fear upon the CNA's presence. Despite these reports, the facility's management acknowledged that the incident was not reported to the appropriate authorities, as required by their policy and federal regulations.
Failure to Conduct Comprehensive Abuse Investigation
Penalty
Summary
The facility failed to implement its abuse policy and procedure (P&P) related to the investigation of physical abuse for one of the sampled residents. The facility's P&P, revised in November 2017, requires a thorough investigation involving interviews with the person(s) reporting the incident, any witnesses, the resident, staff members from different shifts, the resident's roommate if appropriate, family members, and other residents to whom the accused employee provides care. Additionally, the findings of the investigation must be reported to the appropriate agencies within five working days. However, in this case, the facility did not conduct a comprehensive investigation as required. The deficiency involved a resident who was admitted with a diagnosis of hemiplegia and hemiparesis affecting the right dominant side. An anonymous complainant alleged that a Certified Nursing Assistant (CNA) abused the resident. The incident was reported to the Administrator and Director of Nursing (DON) by a family member and the Activity Director. Despite this, the DON confirmed that only the alleged perpetrator, CNA 1, was interviewed, and the alleged abuse was not documented. This failure to conduct a thorough investigation posed a risk for potential abuse to remain unidentified and for residents to go unprotected.
Failure to Provide Adequate Foot Care and Monitoring
Penalty
Summary
The facility failed to provide necessary foot care services for a resident with severe cognitive impairment and Type 2 Diabetes Mellitus, who was at risk for altered skin integrity. The resident had received podiatry care for a fungal infection, which included debridement and nail trimming. However, the facility did not ensure proper skin checks, accurate assessments, or monitoring of the resident's feet following the podiatry care. There was no documentation of a care plan addressing the fungal infection or monitoring of the debridement site and pain assessment. On a subsequent date, a change in the resident's condition was observed, including swelling, redness, and minimal drainage of the right foot and second toe. This change was reported by a CNA, and the resident was transferred to an acute care hospital as ordered by the physician. During an interview, the DON confirmed the absence of documentation for monitoring, assessment, and care planning related to the resident's foot care following the podiatry procedure.
Failure to Implement Non-Pharmacological Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide non-pharmacological interventions for a resident who was prescribed Lexapro, a psychotropic medication, for depression characterized by tearful episodes. Despite the facility's policy, which emphasizes minimizing medication use through non-pharmacological approaches, there was no documented evidence of such interventions being implemented for the resident. The resident's medical records showed multiple episodes of tearfulness across various shifts in August and September, yet no non-pharmacological strategies were recorded or included in the care plan. During an interview and medical record review, the Director of Nursing (DON) confirmed that the resident was monitored for side effects and tearfulness but acknowledged the absence of documentation for non-pharmacological interventions. The care plan also lacked any mention of non-pharmacological measures related to the use of Lexapro. This oversight had the potential to lead to adverse complications for the resident due to the continued reliance on medication without exploring alternative interventions.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for three residents. Resident 2's pressure injuries were not measured and assessed weekly, and no pictures were taken as per the facility's protocol. Resident 2 had multiple infected wounds, including a Stage 4 pressure injury to the sacrum and right lateral knee, and unstageable pressure injuries to various parts of the body. Despite receiving daily wound treatments, there was no documented evidence of weekly wound assessments, including measurements and photos, between 7/22/24 and 9/2/24. Additionally, the facility did not properly adjust the low air loss mattresses for Residents 2, 4, and 5 according to their weights, as required by the facility's policy. Resident 2's mattress was set at levels 8-9, which was too firm for their weight of 166-173 lbs, potentially increasing pressure on the sacral area. Similarly, Resident 4's mattress was set at levels 7-8, which was appropriate for a person weighing 250 lbs, while Resident 4 weighed 182.1 lbs. Resident 5's mattress was also set at levels 7-8, despite their weight being 160-165.4 lbs, and a label on the control panel indicated the correct setting should have been 5-6. These failures posed a risk for the residents to develop new pressure injuries or for existing injuries to worsen. The facility's Director of Nursing (DON) was informed and verified the findings, acknowledging the discrepancies in mattress settings and the lack of documented weekly wound assessments for Resident 2.
Infection Control Lapses in Wound Care and Resident Handling
Penalty
Summary
The facility failed to implement and maintain its infection control program for two of six sampled residents, as evidenced by several lapses in following Enhanced Barrier Precautions (EBP) during wound care and resident handling. Licensed Vocational Nurse (LVN) 1 did not wear a disposable gown as required by EBP when performing wound care on Resident 2, who had multiple infected wounds. Additionally, LVN 1 failed to establish a clean field for wound care supplies, placing them directly on Resident 2's bed, which is against the facility's policy. LVN 1 acknowledged these oversights, citing an allergy to gowns as a reason for non-compliance, although no allergic reaction was observed during the procedure. LVN 3 also failed to adhere to EBP by not wearing a disposable gown while performing wound care on Resident 2, despite the presence of EBP signage indicating the necessity of gown and glove use. LVN 3 admitted to placing wound care supplies on the bed instead of using the overbed table, which was occupied by Resident 2's personal items. This practice contradicts the facility's policy, which requires the use of a clean field for wound care supplies to prevent cross-contamination. Certified Nursing Assistant (CNA) 1, along with a student, did not wear disposable gowns while transferring Resident 6, who was on EBP due to an indwelling urinary catheter and wounds. The Infection Preventionist (IP) confirmed that staff should wear gowns during high-contact activities such as transferring residents on EBP. These failures in following infection control protocols pose a risk of spreading disease-causing microorganisms and infections among residents.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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