Inland Valley Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pomona, California.
- Location
- 250 W. Artesia Street, Pomona, California 91768
- CMS Provider Number
- 056431
- Inspections on file
- 124
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 56
Citation history
Health deficiencies cited at Inland Valley Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
The facility failed to maintain an audible call light system and to respond promptly to call lights, affecting two residents with intact cognition who were dependent on staff for most ADLs. One resident’s call light remained on for extended periods without response while the resident requested assistance for thirst, and another resident reported that staff did not come when the call light was used and felt forgotten by nursing staff. A CNA reported answering a call light only after seeing the blinking light above the door, not hearing it, and an LVN confirmed that call lights should be answered promptly by all staff. Testing of call lights on two units showed that activating call lights did not produce an audible signal at the nurses’ station or in the hallway, despite facility policy and the DON’s expectation that a sound box should beep when a call light is on, and policies required timely response and reporting of defective call lights.
Two residents with intact cognition and dependence on staff for most ADLs did not have bedside water pitchers and reported only receiving small amounts of fluids when requested or only at mealtimes, despite feeling thirsty and having dry mouths. Observations confirmed the absence of water pitchers and cups in their rooms. A CNA not assigned to one resident eventually brought a pitcher after noticing it was missing, while the assigned CNA stated they only provided water upon request. An LVN and the DON both stated that all residents who can swallow and are not on fluid restriction must have bedside water pitchers and that nursing staff are responsible for ensuring this, in line with facility policies on accommodating needs and supporting ADLs.
A resident with dementia and significant ADL dependence was found to have an inoperable, uncovered light fixture above the bed, with no other light source in the room except the roommate’s light. Maintenance staff identified that a repair need had been logged days earlier, but the light remained nonfunctional at the time of surveyor observation, and the Maintenance Supervisor could not produce a corresponding work order. This condition did not meet the facility’s policy requiring comfortable and adequate lighting to support a safe, homelike environment.
A resident with intact decision-making capacity and multiple medical conditions, including a tibia fracture and DM, repeatedly requested to see the Case Manager (CM) to discuss care and discharge planning related to HMO coverage. Nursing staff reported informing the CM of these requests but did not follow up, and the CM did not meet with the resident or document any contact for an extended period after admission, despite a job description requiring monitoring HMO residents and discussing discharge plans. The facility’s social services policy required providing medically related social services, including educating residents about health care options and assisting with psychosocial concerns, yet the resident remained unaware of the discharge plan and experienced mental stress due to the lack of CM involvement.
The facility failed to follow its grievance policies by not ensuring staff could direct complainants on how to file written grievances, and by not thoroughly investigating or documenting grievances submitted by two residents and a representative. One resident’s representative reported multiple care concerns, including hygiene, call light response, food temperature, physician visits, and dental care, but the facility only documented investigation of some issues and did not provide verbal or written findings. Another resident reported waiting two hours for CNA assistance to get into bed, yet no investigation was documented and no follow-up discussion or written report was provided to the resident.
A resident with DM2, dementia, and an anxiety disorder, who required staff assistance with ADLs, was housed in a room where the sliding screen door to an outside patio would not latch or lock. A family member reported the problem to a nurse, who stated it would be entered into the maintenance log. Review of the log showed an entry noting the screen door was not locking, but no completion date, and later observation confirmed the door still did not latch or lock. The maintenance staff confirmed the door needed a new latch and that their policy requires maintaining the building and equipment in a safe and operable manner.
A resident with decision-making capacity and independence in most ADLs yelled at another cognitively impaired, dependent resident and that resident’s family member, and verbally threatened to do something bad to the other resident. A SSA documented the threat and informed the SSD but did not directly notify the ADM or ensure timely reporting as required. The ADM later stated that both the SSA and SSD, as mandated reporters, failed to report the verbal threat as an allegation of abuse in accordance with facility policy, which requires immediate internal notification and reporting to appropriate agencies within two hours.
A resident with DM, dementia, and anxiety, who required staff assistance with hygiene, had a physician order to consult with a podiatrist and had previously been seen for dystrophic and elongated toenails with a recommendation for routine foot care in 60 days. The resident’s family later observed dark brown, peeling toenails and reported this to the DON, who indicated the need for a podiatry visit. However, the resident was not scheduled for the recommended follow-up due to an insurance change and the resident’s name being placed on the wrong podiatry list, contrary to the facility’s foot care policy.
A resident with diabetes, dementia, and anxiety disorder required staff assistance with several ADLs and had documented complaints of abdominal pain in nursing notes. However, over multiple required visits, the NP photocopied the same prior Attending Progress Note, changing only the date, with each note stating there were no complaints and a non-tender abdomen. This resulted in a lack of original, visit-specific physician progress notes as required by OBRA-related policy and had the potential to lead to overlooked changes in the resident’s health status and compromised physician oversight.
A resident with diabetes, dementia, and anxiety, who required staff assistance with oral hygiene, had loose and missing upper teeth and reported needing false teeth. The resident’s family member also reported deteriorating teeth and a need for dental care, stating that no treatment had been provided despite a dental visit. During that visit, the resident refused treatment until the dentist spoke with the family member, but the dental note did not specify the proposed treatment, and there was no evidence the requested discussion occurred. The facility did not ensure timely follow-up or coordination with the dental provider, leaving the resident’s dental deterioration untreated despite a policy stating that routine and emergency dental services are available to meet residents’ oral health needs.
A resident with DM2, dementia, and an anxiety disorder, who had no cognitive impairment per MDS and required assistance with several ADLs, reported that food was sometimes too cold. During a noon meal observation, staff delivered trays from a cart left in the hallway, and the resident’s pureed lunch items were found to be below the facility’s required hot food temperatures, with the pureed chicken at 104°F and cauliflower at 118°F. The resident described the chicken as lukewarm, while the Food Service Manager stated hot foods should be served around 145°F and acknowledged that trays sitting in the hallway can cause temperatures to drop, contrary to the facility’s policy requiring hot foods to meet minimum holding and delivery temperatures.
Two residents who required staff assistance for toileting hygiene were left wet or soiled during nighttime hours due to staffing shortages, despite care plans and facility policies requiring staff to keep them clean and dry. Both residents were dependent on staff for ADLs, and their needs for peri-care were not met as documented in interviews and record reviews.
Two residents with significant care needs were left wet or soiled during nighttime hours due to insufficient CNA staffing, as confirmed by staff interviews and assignment records. CNAs were assigned to care for more residents than outlined in the facility's staffing assessment, resulting in incomplete care tasks and residents being left unkempt by morning.
A resident with severe cognitive and physical impairments developed multiple open wounds and skin breakdown on the right hand after staff failed to correctly apply a palm protector as directed by rehabilitation staff and did not report observed skin issues or bleeding to licensed nursing staff. The resident's care plan and physician orders required monitoring and prompt reporting of skin integrity concerns, but these were not followed, leading to untreated wounds.
Two residents with medical conditions requiring supervision were allowed to smoke on the patio without direct visual oversight, as the assigned staff member was seated inside and unable to monitor them. Both residents had care plans indicating the need for supervision during smoking, and facility policy required staff to maintain visual contact. Staff interviews confirmed that unsupervised smoking was not permitted due to safety concerns, but the required supervision was not provided during the observed incident.
A resident with moderate cognitive impairment and multiple medical conditions was injured after being pushed by her severely cognitively impaired roommate, who had a known history of aggressive behaviors. The incident followed an argument and resulted in the resident sustaining a head laceration and elbow fracture, requiring hospital treatment. Staff responded after the altercation, despite existing care plans and policies addressing aggressive behaviors.
A resident with complex medical needs was discharged to an ICF without the facility communicating the resident's medical conditions or care requirements to the receiving provider. Upon arrival, the ICF determined it could not meet the resident's needs due to unreported conditions, and there was no evidence that the facility had provided the necessary transfer information as required by policy.
A resident and their legal representative were not provided timely access to complete medical records as required by facility policy, despite proper authorization and repeated requests. The facility sent incomplete records and did not adhere to the required timeframe for providing electronic records, as confirmed by the Director of Medical Records.
A resident with end stage renal disease and intact cognition was given four melatonin tablets by an LVN without a physician's order. The LVN administered the supplement upon the resident's request without verifying the order, contrary to facility policy requiring medications to be given as prescribed. The incident was confirmed through interviews and record review, including input from the DON.
Two residents experienced unsanitary and non-homelike conditions due to stained and unclean privacy and window curtains in their rooms. Despite repeated notifications from a family member and one resident over several months, housekeeping did not address the issue, and staff confirmed the curtains were not clean during observations.
A resident with severe cognitive impairment and total dependence for care developed a maggot infestation in the ear, nostril, and mouth after staff failed to provide thorough oral care and the facility did not maintain effective pest control, resulting in flies entering the building and inadequate hygiene practices.
A CNA failed to treat three residents with dignity and respect by slapping a resident's hand, speaking rudely, refusing to change a television channel, and delaying perineal care. These actions left the residents feeling upset, frustrated, and that their needs were not met, in violation of facility policy and residents' rights.
A resident admitted with neurological deficits following a cerebral infarction was discharged from PT after four days and OT after five days, despite orders and evaluations recommending six sessions per week for four weeks. Therapy records and staff interviews indicated the resident was making progress and would have benefited from continued therapy, but services were discontinued prematurely, resulting in the resident not receiving the required rehabilitative care.
The facility did not ensure that doors were closed and window screens were intact, resulting in flies and gnats entering resident rooms and common areas. Staff and residents reported frequent sightings of pests, particularly in rooms with food and drinks, and the outdoor dumpster was observed to be uncovered and overflowing. The issue was especially concerning for residents in the subacute unit who were immobile and unable to protect themselves.
A resident with decision-making capacity received a COVID-19 vaccine without providing informed consent. The vaccine was administered after staff sought consent from a family member, who was not contacted, instead of the resident. The resident was not informed the injection was a COVID-19 vaccine and did not consent to the procedure.
A resident with severe cognitive impairment and multiple pressure injuries did not receive physician-ordered wound care. Nursing staff failed to treat a stage 3 pressure injury on the right knee and did not follow orders for a stage 4 sacrococcyx wound, using the wrong cleanser and omitting zinc oxide. The facility's policy required adherence to physician orders for wound care.
A resident's room was found to be crowded with personal items and had eight plugs connected to two electrical outlets at the head of the bed. Staff were aware of the clutter and had reported it to the Social Services Director and Administrator, but the issue of multiple plugs was not addressed until later. Facility policies require maintenance of a safe and hazard-free environment.
A shower room was found to have two holes in the wall at the base of the tile, with no documentation of repair requests in the maintenance logs. The maintenance worker acknowledged the issue as a safety hazard, and facility policy requires the building to be kept in good repair and free from hazards.
A resident with a history of constipation and decreased mobility developed abdominal distension, firmness, severe pain, and shortness of breath, but nursing staff failed to promptly notify the physician of these significant changes. Despite worsening symptoms and lack of response to treatment, the physician was only informed of constipation, not the full clinical picture. The resident was later found unresponsive with coffee ground emesis and was pronounced dead after unsuccessful resuscitation efforts.
A resident with a history of COPD and chronic respiratory failure experienced abdominal pain, distension, and shortness of breath, but nursing staff failed to perform complete assessments or document pain levels as required by policy. Staff also increased the resident's oxygen without first checking oxygen saturation and did not consistently communicate full assessment findings to the physician. The resident's symptoms persisted and the resident was later found unresponsive and pronounced deceased.
A resident with a history of psychosis and muscle wasting experienced a change of condition involving constipation, abdominal pain, and bloating. Nursing staff failed to fully document assessments and symptoms, including pain severity and abdominal findings, in the medical record. Key information was omitted from the MAR, Progress Notes, and SBAR forms, despite facility policies requiring complete and accurate documentation of changes in condition and care provided.
Four residents experienced a lack of dignity and respect, including a resident startled awake by an LVN making a loud noise in a dark room, another left with unclean and unlabeled urinals, a resident subjected to rude staff interactions and loud joking near their room, and a dependent resident left in a hallway without proper clothing, compromising privacy.
A deficiency occurred when numerous residents, many with complex medical needs and dependent on staff for ADLs, did not receive scheduled showers or hygiene care due to frequent staffing shortages and the absence of a dedicated shower nurse. CNAs were often assigned to care for a high number of residents, making it difficult to provide necessary assistance with bathing, oral care, and timely response to call lights. Staff and residents reported missed showers and delays in care, and facility records confirmed that required ADL support was not consistently provided.
A review found that insufficient nurse staffing on multiple shifts led to unmet care needs for residents with complex medical conditions, including missed showers, delayed call light responses, and incomplete personal care. Staff interviews confirmed that high resident assignments and frequent call-offs resulted in the absence of a dedicated shower nurse and overwhelmed CNAs, preventing them from providing scheduled showers and other essential care. Residents reported not receiving scheduled showers or timely assistance, and documentation confirmed that staffing levels often fell below the facility's stated goals.
Multiple residents did not receive medications as prescribed due to late administration, improper preparation of medications for G-tube delivery, and lack of medication supply. A nurse mixed and administered several medications together via G-tube without following best practices, and medications were not given within the required time frames. One resident missed a scheduled injection for rheumatoid arthritis due to supply issues, resulting in increased pain and rigidity.
Multiple rooms and common areas were found to have persistent cleanliness and maintenance issues, including stained privacy curtains, dirty baseboards, damaged walls, and water-stained ceilings. A resident reported dried blood on a privacy curtain that had not been changed for months, while another pointed out holes and chipped paint behind a bed. Staff interviews revealed inconsistent reporting and follow-up on environmental problems, and facility records lacked clear documentation of maintenance activities.
Surveyors observed multiple holes and cracks in floor tiles in two facility stations, including large holes at room doorways and around a hallway drain, as well as cracks near the beauty salon. The Administrator confirmed these conditions were not homelike and could lead to falls, in violation of the facility's maintenance policy.
A resident with significant medical needs was observed smoking without staff supervision and had a lighter unsecured in their room, contrary to facility policy requiring supervision and secure storage of smoking materials. Staff interviews and records confirmed these requirements were not met.
A resident at high risk of falls fell to the floor due to the facility's failure to attach a tab alarm as ordered. The resident, with conditions such as hemiplegia and COPD, had a physician's order for a tab alarm to alert staff of unassisted transfers. Despite this, the alarm was not attached, and it did not sound during the fall. Staff interviews and observations confirmed the alarm was not functioning as intended, contrary to facility policy and the manufacturer's instructions.
The facility failed to properly dispose of garbage and refuse, as eight dumpsters were found with open lids, contrary to the facility's policy. This was confirmed during an observation and interview with the Director of Food Services and Environmental, who acknowledged the risk of rodents entering the dumpsters. The facility's policy requires dumpsters to be kept closed and free of surrounding litter.
The facility failed to maintain a functioning call light system in 12 resident rooms, potentially delaying care. A resident reported a non-working call light, and maintenance confirmed several rooms had inoperable lights. Additionally, one call light was inaccessible to a resident. Interviews with staff emphasized the importance of call lights for communication and timely assistance, but facility policies were not adhered to.
A resident with a history of aggressive behavior physically and verbally abused another resident, resulting in an injury. Despite the facility's abuse prevention policy, the resident was not protected from these incidents.
A resident with severe cognitive impairment and multiple diagnoses did not receive the required PT and OT services as outlined in their care plan. Despite evaluations recommending treatment six times a week for four weeks, the resident only received one session of each therapy due to insurance authorization issues. The facility's policy mandates comprehensive care plans with measurable objectives, which were not implemented.
The facility failed to provide proper care for two residents with G-tubes. One resident's head of bed was not elevated to the required angle during feeding, and another resident's G-tube was not flushed between medications. Both residents were severely impaired and dependent on staff.
A resident with significant medical conditions did not receive the prescribed Physical Therapy (PT) and Occupational Therapy (OT) services as outlined in their care plan. Despite evaluations indicating the need for therapy, the facility did not provide the services due to awaiting insurance authorization, which was not received. The Director of Nursing confirmed that therapy should be provided based on evaluations and care plans, regardless of insurance status.
A facility failed to follow its policy for timely reporting of abuse allegations when a housekeeper observed a CNA sitting on a resident's bed and did not report it immediately. The facility also did not report the incident to the CDPH within the required timeframe, compromising the resident's safety.
The facility failed to complete 72-hour neurological assessments for two residents involved in an altercation, missing documentation on pain responses and motor function. Additionally, the facility did not monitor or document the condition of a Covid-19 positive resident in the red zone over several shifts, leading to a delayed response to the resident's deteriorating condition.
Two residents were exposed to cigarette smoke due to staff smoking near their room window, preventing them from enjoying fresh air. Both residents, who valued fresh air and had intact cognition, were bothered by the smoke. Observations confirmed staff smoking in the designated area outside their window, contrary to facility policies on maintaining a homelike environment.
A resident with left-sided hemiparesis was unable to reach their call bell due to it being placed on the affected side, contrary to facility policies. This issue was confirmed by the resident, their roommate, and an LVN, highlighting a failure to accommodate the resident's needs as per the facility's procedures.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
Failure to Maintain Audible Call Light System and Timely Response to Resident Calls
Penalty
Summary
The deficiency involves the facility’s failure to ensure the call light system was audible and that call lights were answered in a timely manner, resulting in unmet needs for two residents. Resident 1 was admitted with myasthenia gravis and sequelae of cerebral infarction, had intact cognitive skills and decision-making capacity, and was dependent on staff for most ADLs, including transfers. Resident 1 reported that when using the call light, no one came or it took a long time for staff to respond, causing the resident to feel ignored. On one observation outside Resident 1’s room, the call light remained on and unanswered for 25 minutes. In a concurrent observation and interview inside the room, Resident 1 stated the call light had been on for over 30 minutes without response, and that the resident wanted assistance for dry mouth and thirst. Resident 2, admitted with hemiplegia and diabetes mellitus, also had intact cognitive skills and was dependent on staff for most ADLs, including transfers, and was documented as alert and oriented. Resident 2 stated there was no point in using the call light because nursing staff did not answer it, and that whenever the call light was pushed, no one came to see what was needed. Resident 2 reported feeling that staff did not care and had forgotten about the resident, and expressed concern that an emergency could occur without staff awareness. These resident interviews demonstrated that their calls for assistance were not being reliably answered. Staff interviews and observations further showed that the call light system was not functioning audibly as intended. A CNA reported answering Resident 1’s call light only because the blinking light above the door was seen, not because the call light was heard, and the CNA did not know how long the light had been on. An LVN stated that call lights should be answered promptly by all staff and that if the responding staff member could not assist, they should notify someone who could, emphasizing that unanswered call lights could delay care and potentially cause life-threatening situations. During testing of call lights on two units, the LVN demonstrated that activating call lights in random rooms did not produce an audible sound at the nurses’ station or in the hallway, despite the DON’s description that each unit’s nurses’ station should have a call light sound box that beeps when a call light is on. Facility policies on answering call lights and accommodation of needs required timely response to residents’ requests and prompt reporting of defective call lights, but the observations and interviews showed these requirements were not met.
Failure to Provide Bedside Water Pitchers to Maintain Resident Hydration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received fluids consistent with their needs and preferences to maintain hydration, specifically for two residents who did not have water pitchers in their rooms. One resident was admitted with myasthenia gravis and sequelae of cerebral infarction, had intact cognitive skills, and was dependent on staff for most ADLs including transfers. This resident reported not having a water pitcher, receiving only small cups of water when requested, and experiencing dry lips and throat. On a subsequent day, the resident’s call light had been on for over 30 minutes while the resident was waiting to request water due to thirst and a dry mouth. Another resident, admitted with hemiplegia and diabetes mellitus, also had intact cognitive skills and was dependent on staff for most ADLs including transfers. This resident reported not being given a water pitcher and stated that water and juices were only provided during mealtimes. Observations confirmed there were no cups and no water pitcher in this resident’s room. Both residents were described in clinical documentation as alert, oriented, and capable of making decisions, yet they lacked ready access to fluids at the bedside. Staff interviews further clarified the circumstances leading to the deficiency. A CNA who was not assigned to one of the residents brought a water pitcher after noticing its absence and stated that all residents should have a water pitcher at the bedside to prevent dehydration. An LVN stated that all residents who can swallow and are not on fluid restriction must have a water pitcher at their bedside and that all staff are responsible for providing water. The CNA assigned to one of the residents stated they only provided water if the resident requested it and had assumed the resident did not need water when the resident answered “no” to a general offer of assistance. The DON stated that all residents who can swallow and are not on fluid restriction must have water pitchers at their bedside, that pitchers should be changed daily and as needed, and that nursing staff are responsible for assuring all residents have a water pitcher, consistent with facility policies on accommodation of needs and supporting ADLs.
Failure to Maintain Operable Bedside Lighting for Dependent Resident
Penalty
Summary
The facility failed to ensure an operable light fixture above one resident's bed, compromising the resident's right to a safe, comfortable, and homelike environment. The resident had been readmitted with diagnoses including cholecystitis and dementia, with documentation indicating capacity to make medical decisions but moderately impaired cognitive skills for daily decision-making. The resident required substantial to maximal assistance with upper body dressing, toileting, and personal hygiene, and was dependent on staff for showering, lower body dressing, footwear, and transfers in and out of bed. During observation, the light fixture above the resident's bed was found to be inoperable and missing its cover, and there was no other light in the room except the roommate's bed light. Maintenance staff reported that a work order had been entered on the day of the observation, but also identified a prior entry in the maintenance log indicating the need for repair two days earlier. The Maintenance Supervisor was unable to provide a work order for the light fixture repair and acknowledged that lighting was important for CNAs to see during care and for safety. The facility's policy on a homelike environment required comfortable and adequate lighting in all areas, emphasizing sufficient general lighting in resident-use areas, which was not met in this resident's room.
Failure to Provide Medically Related Social Services and Discharge Planning Support
Penalty
Summary
The facility failed to provide medically related social services to a resident when the Case Manager (CM) did not meet with the resident despite multiple requests. The resident was admitted with a right tibia fracture, diabetes mellitus, and hypotension, and had HMO insurance. The resident’s History and Physical and MDS documented that the resident had intact cognitive skills for decision-making and required substantial/maximal assistance for most ADLs. During a phone interview, the resident reported making many requests through nursing staff to see the CM and stated being told that the CM, not the facility social workers, was responsible for coordinating care and discharge for HMO residents. RN 1 confirmed remembering the resident’s request and stated that the CM was informed but RN 1 did not follow up. Review of the electronic medical record showed no CM notes indicating any meeting or discussion with the resident until 14 days after admission, although the CM acknowledged they should have seen the resident earlier and did not. The DON reviewed the CM’s job description, which stated that the CM is responsible for monitoring all HMO/managed care residents for care needs and orders, and for discussing discharge plans with residents to ensure the plan and level of care meet their needs and ability to participate. The facility’s Social Services policy stated that medically related social services are provided to help residents attain or maintain their highest practicable physical, mental, or psychosocial well-being, including informing and educating residents about health care options and assisting with factors negatively affecting psychosocial functioning, such as helping residents voice and resolve grievances. The failure of the CM to meet with the resident from 2/10/2026 to 2/23/2026 resulted in the resident being unaware of the discharge plan and experiencing mental stress.
Failure to Investigate and Communicate Resident Grievances as Required
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances and to have those grievances promptly and thoroughly investigated and communicated. Staff interviews showed that some RNs did not guide residents or representatives on how to file written grievances, did not know where grievance forms were located, and did not know who the facility’s Grievance Officer was, despite facility policy requiring staff to provide this information. The facility’s written grievance policies required that all grievances be investigated, that the Grievance Officer initiate investigations, and that complainants be informed verbally and in writing of the findings and corrective actions. One affected resident, identified as Resident 6, was admitted with type 2 diabetes mellitus, dementia, and anxiety disorder, and required staff assistance with bathing, dressing, toileting, and personal hygiene. Resident 6’s representative submitted a written grievance on 10/16/2025 alleging that the resident’s clothing and bedding had not been changed for a week, that the resident was not being showered, that call lights were not answered timely, that food was not served warm leading to weight loss, that the physician was not visiting, and that a dental appointment had not been arranged. The grievance form’s investigation section only addressed the concerns about showers and changing clothes and linens, and did not document any investigation into the complaints about call light response, food temperature, weight loss, physician visits, or dental arrangements. The Social Services Director reported only leaving a message for the representative and did not speak with the representative about the investigation results, and no written report of findings was provided to the representative. Another affected resident, identified as Resident 17, had a history of falls, bone density disorder, and osteoarthritis, with moderate cognitive impairment and a need for substantial/maximal assistance with bathing, lower body dressing, and personal and toileting hygiene. This resident filed a grievance on 1/23/2026 stating that they waited two hours for CNA assistance to get into bed after being left in the hallway. The grievance form for this complaint contained no documented investigation report. The resident stated that no one from the facility spoke with them about the grievance after it was filed. The Social Services Director acknowledged not following up with the resident and not providing a written report, and the Director of Staff Development stated they did not investigate the grievance because they were never informed of it. These actions and omissions conflicted with the facility’s grievance policies, which required investigation of all grievances and verbal and written notification of findings to the complainant within five working days.
Failure to Repair Resident Room Sliding Screen Door Lock
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for one resident when the sliding screen door in the resident's room would not latch or lock. The resident had been admitted with type 2 diabetes mellitus, dementia, and an anxiety disorder, and an MDS assessment indicated no cognitive impairment and a need for staff assistance with bathing, dressing, oral care, toileting, and personal hygiene. The resident's family member reported to an unidentified nurse that the sliding screen door handle in the resident's room would not latch and lock, and the nurse stated they would write a maintenance request in the Maintenance Log at the nurses' station. Subsequent observation showed that the sliding screen door to the outside patio, which provided access to the back of the facility, still would not latch closed and the lock/unlock tab would not slide up or down. Review of the Maintenance Log revealed an entry for this resident's room noting that the screen door was not locking, with no completion date documented, indicating the issue had not been fixed or addressed. The Maintenance Assistant confirmed that staff are required to document needed repairs in the Maintenance Log and that maintenance staff sign and date when issues are resolved, and also confirmed that the resident's sliding screen door required a new latch. The facility's maintenance policy stated that the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times.
Failure to Report Resident’s Verbal Threat as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Reporting and Investigation policy when a resident verbally threatened harm toward another resident. Resident 1, admitted with essential hypertension and hyperlipidemia and documented as having decision-making capacity and independence with most ADLs, yelled at Resident 2 and Resident 2’s family member in their shared room. Social Services Assistant (SSA) 1 documented in a social services note on 1/28/2026 that Resident 1 stated that if Resident 2’s family ever addressed Resident 1 again, Resident 1 was going to do something bad to Resident 2. SSA 1 reported this statement to the Social Services Director (SSD) and believed the SSD would inform the Administrator (ADM), but SSA 1 did not directly notify the ADM as required by the facility’s abuse policy. Resident 2, who had diagnoses including hyperlipidemia, history of falling, and depression, was documented as having severely impaired cognition and dependence on staff for multiple ADLs. Resident 2’s family member reported that Resident 1 yelled at everyone in the room and threatened Resident 2, stating Resident 1 would show Resident 2 who Resident 1 was. The ADM stated that neither SSA 1 nor the SSD reported Resident 1’s threat to harm Resident 2 to the ADM, despite both being mandated reporters. The DON stated that verbal threats are a form of verbal abuse and should be reported within two hours to appropriate authorities and to the abuse coordinator. The facility’s Abuse Reporting and Investigation policy required all staff to report all allegations of abuse to appropriate agencies within two hours and to notify the Abuse Prevention Coordinator and their supervisor immediately, which did not occur in this incident.
Failure to Provide Timely Podiatry Follow-Up and Foot Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and assist with podiatry appointments for one resident. The resident was admitted with diagnoses including type 2 diabetes mellitus, dementia, and anxiety disorder. An MDS assessment indicated the resident had no cognitive impairment in decision-making but required staff assistance with bathing, dressing, toileting, oral, and personal hygiene. A physician order dated 12/26/2025 authorized the resident to consult with a podiatrist. During an interview, the resident’s family member reported the resident’s toenails were turning dark brown and peeling, and stated that when this was brought to the DON’s attention, the DON said the resident would need to be seen by a podiatrist. Record review showed that during a podiatry visit documented as a Nursing Home Visit on 10/12/2025, the podiatrist noted dystrophic and elongated toenails and recommended routine foot care again in 60 days. The social services assistant confirmed that this was the resident’s last podiatry visit and that the resident was not seen again in 60 days as recommended. The assistant explained this did not occur due to a change in the resident’s insurance and the resident’s name being placed on the wrong podiatry list. The facility’s foot care policy stated that residents receive appropriate care and treatment to maintain mobility and foot health, which was not followed in this case.
Failure to Document Original Physician Progress Notes at Required Visits
Penalty
Summary
The facility failed to ensure that an attending physician or designee wrote, signed, and dated original progress notes at each required visit for one resident. The resident was admitted with diagnoses including type 2 diabetes mellitus, dementia, and anxiety disorder. A Minimum Data Set dated 12/15/2025 documented that the resident had no cognitive impairment in decision-making and required varying levels of staff assistance for bathing, dressing, oral care, toileting, and personal hygiene. Health Status Notes from early August 2025 showed that the resident complained of abdominal pain. During a concurrent interview and record review with the nurse practitioner (NP) on 2/9/2026, Attending Progress Notes dated across multiple months were examined. The notes for 7/3/2025, 8/4/2025, 9/5/2025, 10/6/2025, 11/7/2025, 12/7/2025, and 1/26/2026 were found to be identical in content, each stating that the resident had no complaints and a non-tender abdomen, with only the date at the top changed. The NP acknowledged photocopying the previous month’s progress note because the NP believed there were no changes in the resident’s condition. This practice conflicted with the facility’s Physician Services policy, which required physician orders and progress notes to be maintained in accordance with current OBRA regulations and facility policy. The report stated that this failure had the potential to result in overlooked changes in the resident’s health status and compromised physician oversight of the resident’s total program of care.
Failure to Coordinate Dental Follow-Up After Resident Requested Dentist-Family Discussion
Penalty
Summary
The facility failed to provide routine dental services to meet a resident's oral health needs by not ensuring timely follow-up or coordination after a dental visit. The resident was admitted with diagnoses including type 2 diabetes mellitus, dementia, and anxiety disorder, and the MDS assessment showed no cognitive impairment and a need for staff assistance with oral and personal hygiene. Observation revealed the resident was missing most upper teeth, and both the resident and a family member reported loose and missing teeth and the need for dental care, including false teeth. The family member stated that if the resident had been seen by a dentist, no treatment had been provided to address the deteriorating teeth. The dental progress note from a dentist visit documented that the resident refused treatment and requested that the dentist speak with the resident’s family member before proceeding. The note did not specify what treatment was refused. The social services assistant acknowledged that the dentist should have spoken with the family member as requested and reported calling the dentist’s office to inform them that the family member wanted to speak with the dentist. The regional manager for the dental provider confirmed the dentist saw the resident and that the resident wanted the dentist to talk with the family member before treatment, but the documentation did not indicate that this occurred. As a result, the resident’s dental deterioration remained untreated, contrary to the facility’s policy stating that routine and emergency dental services are available to meet residents’ oral health needs in accordance with their assessment and care plan.
Failure to Serve Hot Foods at Required Temperatures
Penalty
Summary
The facility failed to ensure hot foods were served at a palatable, safe, and appetizing temperature when a resident received a lunch meal that was below the facility’s required hot food temperatures. The resident, who had type 2 diabetes mellitus, dementia, and an anxiety disorder, had an MDS indicating no cognitive impairment and required varying levels of assistance with ADLs such as bathing, dressing, oral care, toileting, and personal hygiene. The resident reported during interview that sometimes the food served was too cold. During a noon meal observation, the meal tray cart was placed in the hallway near a nurses’ station, and staff began delivering trays a few minutes later, with the resident’s tray delivered several minutes after the cart was opened. Upon observation and temperature testing of the resident’s lunch tray, which consisted of pureed chicken with sauce, pureed cauliflower, pureed pasta, and pureed bread, the pureed chicken measured 104°F and the pureed cauliflower measured 118°F. The resident tasted the chicken and stated it was lukewarm and should be hot. The Food Service Manager stated that hot foods should generally be served around 145°F and acknowledged that if trays sit in the hallway too long, food temperatures will drop. The facility’s Meal Service policy required hot food serving temperatures to be at or above a minimum holding temperature of 140°F, with recommended delivery temperatures greater than 120°F for hot entrées, which was not met for the resident’s pureed chicken.
Failure to Provide Peri-Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary peri-care for two residents who required physical assistance with toileting hygiene. For one resident with diagnoses including epilepsy, type 2 diabetes mellitus, and a history of falls, records indicated a care plan goal for daily ADL needs to be met, with interventions for staff to keep the resident clean and dry. Despite this, the resident reported being left wet during nighttime hours due to staffing shortages. Documentation showed the resident had severely impaired cognitive skills and required supervision to extensive assistance for ADLs. Another resident, with diabetes mellitus and hypertension, was also dependent on staff for toileting hygiene according to their care plan and assessment. This resident reported being left soiled for an extended period during nighttime hours, again citing staffing shortages as the cause. The resident expressed concern about prolonged incontinence and potential skin breakdown. Facility policies reviewed indicated that residents unable to perform ADLs independently should receive necessary services to maintain hygiene, and that perineal care is intended to provide cleanliness, comfort, and prevent infection and skin irritation.
Insufficient Staffing Leads to Delayed Incontinent Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delays in toileting and incontinent care for two residents. One resident, with diagnoses including epilepsy, type 2 diabetes, and a history of falls, was assessed as having severely impaired cognitive skills and required supervision to extensive assistance for activities of daily living. This resident reported being left wet during nighttime hours due to staffing shortages. Another resident, with diabetes and hypertension and intact cognitive skills, was dependent on staff for toileting hygiene and reported being left soiled for an extended period during the night, also attributing this to insufficient staffing. Staff interviews and assignment sheet reviews confirmed that CNAs were assigned to care for more than 16 residents during the night shift, exceeding the facility's own staffing assessment. CNAs reported being unable to complete all assigned care tasks due to excessive workloads, resulting in residents being left wet and unkempt by morning. The facility's policies indicated that staffing should be based on resident needs and care plans, but actual assignments did not align with these requirements, leading to unmet care needs for residents.
Failure to Properly Apply and Monitor Hand Splint Resulting in Skin Breakdown
Penalty
Summary
The facility failed to provide appropriate care and services to a resident with severe cognitive impairment and significant physical limitations, specifically regarding the use and monitoring of a right hand palm protector. The restorative nursing assistants (RNAs) did not correctly apply the palm protector as instructed by rehabilitation staff. The elastic band of the device was placed between the thumb and index finger, contrary to the occupational therapist's directions, which was observed to be incorrect and contributed to skin breakdown. Additionally, the RNAs did not inform licensed nursing staff when they observed that the resident's right palm and hand were sweaty and had moisture accumulation, nor did they report the presence of open wounds and bleeding on the resident's right thumb and index finger after removing the palm protector. The wound/treatment nurse was not notified of these wounds, and the resident's care plan and physician orders specifically required monitoring for skin integrity and prompt reporting of any skin breakdown or pain. Observations and interviews confirmed that the resident was dependent on staff for all activities of daily living and had a history of severe contractures and muscle atrophy. Despite these vulnerabilities and clear care instructions, the palm protector was not applied as ordered, and significant changes in the resident's skin condition were not communicated to the appropriate nursing staff, resulting in multiple open wounds and skin issues on the resident's right hand.
Failure to Provide Adequate Supervision During Resident Smoking Activities
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision for two residents who wished to smoke, as required by the facility's policy and procedure on resident smoking. On the observed date and time, the Activities Assistant (AA) responsible for supervising the smoking patio was seated inside, facing away from the door and unable to visually monitor the residents who were smoking outside. The AA acknowledged not being able to see the residents from their position and stated that visual supervision was important to ensure resident safety and prevent incidents such as burns or altercations. Resident 4 had a history of peripheral vascular disease and lack of coordination, with care plans and assessments indicating a risk for injury related to smoking and a need for supervision during smoking activities. Resident 5 had diagnoses including peripheral vascular disease, muscle wasting, and nicotine dependence, and was also identified as being at risk for injury from smoking or vaping, requiring staff supervision during scheduled smoking times. Both residents' care plans and assessments documented the need for precautionary measures and supervision, and facility policy specified that residents requiring assistance or monitoring for smoking safety were not to smoke unsupervised. Interviews with staff, including an LVN and the Director of Nursing (DON), confirmed that residents were not permitted to smoke without supervision due to safety concerns such as burns, altercations, or potential fires. The DON emphasized the necessity of maintaining visual contact with residents during smoking activities. Despite these requirements, the observed lack of direct supervision placed the residents at risk and constituted a failure to follow established safety protocols.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and multiple medical conditions, including Alzheimer's disease and anxiety disorder, was physically abused by her roommate. The incident took place after an argument between the two residents, during which the roommate, who was severely cognitively impaired and had a documented history of aggressive behaviors, pushed the resident. This resulted in the resident falling to the floor, sustaining a laceration to the back of her head and a fracture to her right elbow, requiring transfer to an acute care hospital for treatment. The roommate involved in the altercation had a care plan in place due to her potential for physical and verbal aggression, including behaviors such as throwing items, yelling, and arguing with other residents. Staff interviews confirmed that the roommate had a pattern of losing her temper and displaying aggressive behaviors toward other residents, both in the room and in common areas. Despite these known risks, the two residents continued to share a room, and staff intervention only occurred after the altercation had already escalated to physical violence. Facility policy required staff to monitor residents for aggressive or inappropriate behaviors and to recognize behaviors that could provoke reactions, such as verbal or physical aggression and invading personal space. In this case, staff responded after hearing the argument and the incident had already resulted in injury. The failure to prevent the altercation and protect the resident from physical abuse constituted a violation of the resident's right to be free from abuse and neglect.
Failure to Communicate Resident Needs Prior to Discharge
Penalty
Summary
The facility failed to arrange for a safe and orderly discharge for one resident when it did not communicate the resident's medical conditions and needs to the receiving Intermediate Care Facility (ICF) prior to transfer. The resident had significant medical diagnoses, including acute kidney failure, malignant melanoma, and dysphagia, and was severely impaired in cognitive skills, requiring substantial to maximal assistance with activities of daily living. Upon arrival at the ICF, staff determined that the resident had bed sores and an infected tumor on the neck, conditions that the ICF was not equipped to manage. The ICF administrator reported not receiving any transfer paperwork or communication regarding the resident's needs before the transfer and stated that the facility was not appropriate for the resident's level of care. The case manager responsible for the discharge confirmed that there was no evidence, such as a fax confirmation or phone call, to show that the resident's medical needs were communicated to the receiving ICF prior to discharge. The facility's policy required comprehensive information to be conveyed to the receiving provider at the time of transfer or discharge, including medical status, care needs, and special instructions, but this was not followed in this instance.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a resident or the resident's legal representative with a copy of the resident's medical record upon request and within the required timeframe, as outlined in the facility's own policy and procedure. The resident, who was admitted with lumbar region stenosis and hypertension and required substantial assistance with activities of daily living, had intact cognitive skills according to the Minimum Data Set. A signed HIPAA-compliant authorization for the release of patient information was present, and a formal request for records was made to the medical records assistant. Despite these requests, the legal assistant reported that the facility continued to send incomplete printed and scanned records instead of the requested electronic format from the Point Click Care system. The facility's policy required electronic access or copies to be provided within 24 to 48 hours, excluding weekends and holidays, when records are maintained electronically. The Director of Medical Records acknowledged that the department did not follow the established policy and procedure, resulting in the resident's representative not receiving the medical records in a timely manner.
Medication Administered Without Physician Order
Penalty
Summary
A medication administration error occurred when a licensed vocational nurse (LVN) gave a resident four tablets of melatonin, totaling 12 milligrams, without a physician's order. The resident, who had end stage renal disease and was dependent on dialysis, was admitted with intact cognition and the ability to make decisions. The error was documented in the resident's records, including the Change in Condition Evaluation and Care Plan Report, which noted the risk for possible adverse reactions and the need for monitoring. The facility's policy and procedure for administering medications requires that medications be given as prescribed, but this was not followed in this instance. The incident was validated through interviews and record reviews, including statements from the resident and the Director of Nursing (DON). The LVN admitted to administering the melatonin upon the resident's request without verifying a physician's order. The facility's policy, reviewed with the DON, clearly states that medications must be administered in accordance with prescriber orders, which was not adhered to in this case.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean and stain-free environment for two residents, as evidenced by observations and interviews. One resident, who was cognitively intact but dependent on staff for mobility and hygiene, had a window curtain with a large brown stain that had been present for several months. The resident's family member reported notifying staff about the soiled curtain approximately three months prior, but no action was taken to address the issue. Another resident, who was moderately cognitively impaired but independent in mobility and hygiene, reported that both the privacy and window curtains in their room were dirty, with visible grease-like stains and a black spot. The resident stated that despite repeated requests over a seven-month period, housekeeping had not cleaned or replaced the curtains. During observations with the housekeeping supervisor, the presence of stains on both residents' curtains was confirmed. The supervisor acknowledged that the curtains were not clean and that the environment was not homelike, attributing the oversight to staff not checking the interior side of the curtains. Facility policy requires a clean, sanitary, and orderly environment, but this standard was not met for these residents, resulting in an unsanitary and non-homelike living space.
Maggot Infestation Due to Inadequate Oral Care and Pest Control
Penalty
Summary
A resident with severe cognitive impairment, total dependence for activities of daily living, and multiple complex medical conditions including end-stage renal disease, respiratory failure requiring mechanical ventilation, and a tracheostomy, was admitted to the facility. The resident required total assistance for oral hygiene, toileting, bathing, and personal hygiene, as documented in the Minimum Data Set and interdisciplinary team records. Staff interviews and record reviews revealed that oral care was inconsistently performed, with some staff only cleaning around the lips and not the inside of the mouth, and not seeking assistance from licensed nurses or respiratory therapists when unable to provide complete oral care. Documentation of oral care was also lacking, and thick white material was observed on the resident's tongue and dried debris on the teeth and gums. Environmental observations and staff interviews indicated that the facility failed to maintain effective pest control measures. Flies and gnats were observed inside the facility, including in resident care areas and the conference room. The facility's trash dumpster was found uncovered and overflowing, and screen doors were not consistently kept closed or intact, allowing insects to enter the building. Staff acknowledged the presence of flies in resident rooms and the importance of keeping doors and windows closed, especially given the vulnerability of residents who were immobile and unable to protect themselves from pests. As a result of these failures, multiple staff members observed five to eight maggots emerging from the resident's right ear, right nostril, and mouth during a dialysis session. The resident was subsequently transferred to an acute care hospital, where diagnoses included septic shock, severe sepsis, and the presence of meal worms in the nostrils. The facility's lack of adherence to oral care protocols and pest control policies directly contributed to the maggot infestation and subsequent harm to the resident.
Failure to Treat Residents with Dignity and Respect by CNA
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to treat three residents with dignity and respect, as evidenced by multiple incidents observed, reported, and documented. One resident, who was dependent on staff for most activities of daily living and had intact cognitive skills, reported that CNA 1 slapped their hand and spoke rudely when the resident requested anti-itch cream for the perineal area. The resident expressed feeling angry as a result of this interaction. Another resident, also cognitively intact and with significant physical limitations, stated that CNA 1 refused to change the television channel upon request, which left the resident feeling upset and that their needs were not being met. A third resident, who was dependent for personal care due to paraplegia and other medical conditions, reported that CNA 1 did not change their incontinence brief in a timely manner, resulting in the resident waiting over an hour for care. This was corroborated by a family member who also requested assistance from CNA 1 and was told that other tasks would be completed first. The resident expressed frustration at not receiving proper care. Facility records, including grievance forms and interviews with staff, confirmed that CNA 1's actions were inconsistent with facility policy, which requires staff to treat residents with dignity, respect, and kindness. Interviews with facility leadership, including the Director of Staff Development and the Assistant Director of Nursing, confirmed that the behaviors exhibited by CNA 1—such as slapping a resident's hand, refusing reasonable requests, and delaying personal care—were not acceptable and violated both facility policy and residents' rights. The facility's policies emphasize the importance of providing care that maintains residents' dignity and comfort, including prompt and respectful assistance with personal needs.
Failure to Provide Prescribed Rehabilitative Services
Penalty
Summary
The facility failed to provide ongoing occupational and physical therapy services as required for a resident who had recently been admitted following a hospital stay for encephalopathy and hemiplegia/hemiparesis after a cerebral infarction. Upon admission, the resident had documented needs for aggressive rehabilitation, with both hospital and facility therapy evaluations recommending skilled therapy at a frequency of six times per week for four weeks. Despite these recommendations, the resident was discharged from physical therapy after only four days and from occupational therapy after five days, significantly short of the planned duration. Therapy records indicated that the resident was making some progress during the brief period of therapy, such as requiring less assistance with certain activities. Both the physical therapist and occupational therapist acknowledged that the resident would have benefited from continued therapy services, and the assistant director of nursing agreed that more therapy should have been provided. The facility's own policies emphasized the importance of providing therapy to improve patient outcomes and required thorough documentation to justify therapy decisions. Interviews with staff and the resident's family member confirmed that the resident did not receive the prescribed rehabilitative services after the initial days of therapy. The lack of continued therapy was attributed to a perceived lack of progress, despite evidence of improvement in the resident's functional abilities. This failure resulted in the resident not receiving the specialized rehabilitative services necessary for their condition, as required by their care plan and physician orders.
Failure to Maintain Effective Pest Control and Screen Integrity
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in flies and gnats being present inside the building. Multiple staff members, including LVNs and CNAs, reported seeing gnats and flies in residents' rooms, particularly where food and drinks were present. Staff indicated that the process for reporting pest sightings involved notifying the Maintenance Department, but observations revealed ongoing issues. The facility's trash dumpster was observed to be uncovered and overflowing, which likely contributed to the pest problem. Additionally, staff interviews confirmed that it was their responsibility to ensure window and door screens were closed and that fly lights were operational, but these measures were not consistently maintained. Several residents reported seeing flies and gnats in their rooms, with some attempting to remove the pests themselves. Observations confirmed the presence of live flies and gnats in common areas such as the conference room. Interviews with nursing and maintenance staff highlighted the importance of pest control, especially for residents in the Subacute Unit who are immobile, unresponsive, and unable to protect themselves from pests. The facility's policy required that windows be screened at all times, but this was not consistently enforced, leading to the entry of insects into resident areas.
Failure to Obtain Informed Consent for COVID-19 Vaccine Administration
Penalty
Summary
The facility failed to obtain informed consent from a resident prior to administering the COVID-19 vaccine. The resident, who had diagnoses including encephalopathy and right-sided hemiplegia following a cerebral infarction, was admitted with documented capacity to understand and make decisions. Despite this, the Infection Prevention Nurse contacted the resident's family member for consent, citing the resident's Spanish-speaking and non-verbal status, rather than obtaining consent directly from the resident. The family member later stated they were never contacted for consent. The resident reported not giving consent for the vaccine and was not informed that the injection was a COVID-19 vaccine, instead being told it would help their right arm move better. Facility policy required that residents or their representatives be given the opportunity to accept or refuse the vaccine. The Assistant Director of Nursing confirmed that, given the resident's capacity, consent should have been obtained directly from the resident.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the formation and promote the healing of pressure injuries for one resident. Specifically, the resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, had physician orders for wound care to treat a stage 3 pressure injury on the right knee and a stage 4 pressure injury on the sacrococcyx. The care plan directed staff to follow these orders, which included cleansing with normal saline, application of collagen powder, Medihoney, calcium alginate, and zinc oxide, and covering with a dry dressing. During observation, the treatment nurse did not perform wound care on the resident's right knee as ordered and did not follow the physician's orders for the sacrococcyx wound. Instead of using normal saline, the nurse used Hibiclens to cleanse the wound and did not apply zinc oxide to the periwound area. The nurse confirmed these deviations during an interview. The Assistant Director of Nursing also acknowledged that following physician orders is essential and that using other products without an order is not acceptable. The facility's wound care policy required verification of physician orders for wound care procedures.
Cluttered Resident Room and Overloaded Electrical Outlets Identified
Penalty
Summary
A deficiency was identified when a resident's room was found to be cluttered with multiple personal items surrounding the bed, and eight plugs were connected to two electrical outlets at the head of the bed. The resident, who was alert, oriented, and independent in activities of daily living, had a medical history including type 2 diabetes, acute kidney failure, anxiety disorder, depression, and nicotine dependence. The room environment was observed to be crowded, and the electrical outlets were overloaded, creating a potential safety hazard. Staff interviews revealed that nursing staff were aware of the clutter and had informed the Social Services Director (SSD) and Administrator, transferring responsibility for addressing the issue. The SSD acknowledged awareness of the clutter but was not informed about the multiple plugs in the outlets until the time of the interview. Facility policies reviewed indicated that maintenance is responsible for keeping the building free from hazards and that staff are expected to maintain a safe, clean, and homelike environment.
Plan Of Correction
F-689 Free of Accident Hazards/Supervision CFR(s): 483.25(d)(1)(2) CORRECTIVE ACTION: On 05/22/2025 upon notification, maintenance staff went into Resident 2 room and removed the eight plug that were connected to the two electrical outlets at the head of the bed. Maintenance staff explained to Resident 2 the risk of fire/accident when numerous items are plugged into one outlet. Resident 2 was explained about not using extension cords and was advised to contact maintenance so they can inspect and give clearance before plugging any electrical items. On 05/22/2025 SSA met with the Resident 2 and discussed room being crowded and cluttered. SSA offered to assist Resident 2 in boxing and packaging some of the unnecessary items. On 05/27/2025 an interdisciplinary Conference was conducted with Resident 2. During the conference with Resident 2, room being cluttered and too many electrical items being plugged into receptacle were discussed. There was no ill effect to Resident 2 from this deficient practice. IDENTIFYING OTHER RESIDENTS AT RISK & CORRECTIVE ACTION On 05/23/2025, Maintenance Team conducted spot check on resident's rooms focusing on room environment and electrical items being plugged and connected to electrical outlets in an unsafe manner. On 05/23/2025 Social Service Team conducted a spot check and observation of resident's rooms to ensure they are clutter free. No other residents were identified to be affected by this deficient practice. SYSTEMIC CHANGES On 05/29/2025 Administrator provided In-services to managers that during their weekly Angel Room Rounds to their assigned rooms ensure the appropriate use of electrical items and ensuring resident's surrounding is clutter free. On 05/29/2025 Administrator provided in- service to social service staff related to providing spot check and observation during their routine weekly rounds to ensure the appropriate use of electrical items and ensuring resident surrounding is clutter free. SSA and Maintenance staff will continue monitoring Resident 2 room through weekly inspection for appropriate and proper use of electrical items and to ensure room is clutter free. Any non-compliance with Resident 2 room will be addressed with corrective actions. Maintenance staff, social service staff, managers and administrator will monitor the compliance by conducting weekly spot checks of resident's rooms to ensure appropriate use of electrical items and ensuring residents surroundings are clutter free. Any non-compliance with this requirement will be reported to DON and/or DSD for immediate corrective action and additional training will be provided if deemed necessary. MONITORING EFFECTIVENESS The results of spot checks and inspections will be analyzed by Maintenance Supervisor and/or Administrator and any findings or non- compliance identified with this deficient practice will be reported to the QAPI Committee quarterly for review and further recommendations. Reporting will continue for three months to ensure compliance is maintained.
Failure to Maintain Safe and Functional Shower Room
Penalty
Summary
The facility failed to maintain a safe and functional shower environment, as evidenced by the presence of two holes in the wall at the base of the tile in one of four shower rooms. This issue was identified during an observation, and it was confirmed that there was no documentation in the maintenance logs indicating that staff had requested repairs for the shower or wall. The maintenance worker acknowledged the lack of documentation and recognized the holes as a safety hazard for residents using the shower room. Review of the facility's maintenance policy indicated that the maintenance department is responsible for keeping the building in good repair and free from hazards at all times.
Failure to Notify Physician of Change in Condition Results in Resident Death
Penalty
Summary
The facility failed to promptly notify a resident's physician of significant changes in the resident's condition, despite clear symptoms and facility policies requiring such notification. The resident, who had a history of constipation and was at risk due to medication use and decreased mobility, experienced abdominal distension, firmness, and pain, and had not had a bowel movement for two days. Although the nursing staff assessed the resident and noted these symptoms, they did not communicate the full extent of the findings—including abdominal distension, firmness, and pain—to the physician. Instead, only the complaint of constipation was relayed, and the physician ordered magnesium citrate. After administration of magnesium citrate, the resident's symptoms did not improve. The resident continued to experience abdominal distension, firmness, and developed shortness of breath requiring increased supplemental oxygen. The resident also reported severe abdominal pain rated 8 out of 10. Despite these worsening symptoms and the lack of response to treatment, the nursing staff did not notify the physician of the resident's deteriorating condition. Instead, communication remained within the nursing team, and the physician was not informed of the new or worsening symptoms, nor was the resident transferred for higher-level care. Ultimately, the resident was found unresponsive with coffee ground emesis, was not breathing, and had no pulse. Emergency services were called, and resuscitation efforts were unsuccessful. The physician later confirmed that, had they been notified of the full clinical picture, additional interventions such as diagnostic imaging or hospital transfer would have been considered. The failure to notify the physician of the resident's change in condition was identified as a deficiency by the survey agency, as it prevented timely medical intervention and contributed to the resident's rapid decline and death.
Removal Plan
- An in-service was initiated by the DON and the Assistant DON to all licensed nursing staff (all RNs and LVNs) on contacting the physician as soon as possible for any resident's COCs specifically for residents with constipation, abdominal pain, abdominal distention, and abdominal firmness; contacting the resident's physician as soon as possible when there is a delay in medication and when a resident's symptoms do not improve or worsen during a COC; ensuring accurate, complete, and timely documentation; completing an accurate assessment of the residents' overall condition and thorough documentation.
- The DON provided an in-service to direct care staff including nursing assistants in recognizing subtle but significant changes in the resident condition and how to communicate these changes to the LNs. CNAs were re-educated and encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the residents' condition.
- The medical records team conducted an audit of change in a resident's condition or status with emphasis on timely physician notification. The audit results showed residents were identified as not having a BM for three days.
- The facility identified residents who had no BM for three days, the residents were assessed by assigned LNs and the steps stated below were followed. The audit results are reviewed by the RN Supervisor to ensure: any changes to the residents' condition are communicated to the primary physician for any recommendations and for new orders; the nursing team has documented in the residents' medical record relative to changes in the residents' medical/mental condition or status; the residents' CP is updated to reflect the residents' COCs; the licensed nursing staff documents in the residents' clinical record for the COC reported or assessed by licensed nursing staff; the RN Supervisor has validated the completion of the SBAR by LNs.
- The DON and Regional Clinical Consultant initiated Competency Skill Checks for all RNs on COCs, notification of physicians, changes/worsening conditions, specific system assessment with emphasis on bowel management, Point Click Care clinical alert and hand-off communication. Competency Skill Checks will be completed for any RN currently on medical leave or vacation before providing patient care. In-services will be continued by the DON until all licensed staff are re-educated.
- The facility has created a bowel management tool for significant COCs identifying the need to notify the physician. LNs are responsible for identifying significant COCs on bowel management: License nurses will identify Residents who have not had BMs for 72 hours, with new or worsening symptoms, and other associated abnormal changes but not limited to frequency and consistency of bowel, abdominal pain, abdominal distension, decreased peristalsis, and signs of GI bleeding; upon identification LNs will utilize the tool and document the notification of the physician; LNs will continue documenting the COCs through the SBAR in the clinical health records; LNs will obtain recommendations from the physicians and will carry the recommendations out; the tool will be completed daily during each shift by the charge nurses, the tool will be collected by medical record staff and retained for review.
- The medical records team also conducted an audit of the alert system in PCC. The PCC alert notifies the nursing team when a resident does not have BMs for 24 hours or more.
Failure to Perform Comprehensive Assessment During Change of Condition
Penalty
Summary
The facility failed to conduct thorough and timely assessments for a resident who experienced a change of condition related to abdominal pain, distension, and respiratory distress. Multiple nursing staff, including RNs and LVNs, did not fully assess the resident's abdomen for distension, firmness, rebound, guarding, bowel sounds, or pain at various points when the resident reported symptoms of constipation, abdominal discomfort, and shortness of breath. Documentation and interviews revealed that assessments were incomplete or not performed, and that pain levels were not consistently evaluated or communicated to the physician. The resident, who had a history of COPD, chronic respiratory failure, and muscle wasting, was admitted and readmitted with these diagnoses. The care plan indicated the resident was at risk for discomfort and shortness of breath due to COPD and required oxygen therapy. Despite complaints of not having a bowel movement for two days, abdominal pain, and bloating, the nursing staff did not perform comprehensive gastrointestinal assessments as required by facility policy. Additionally, when the resident requested an increase in oxygen due to difficulty breathing, staff increased the oxygen flow without first assessing the resident's oxygen saturation. Communication lapses were also evident, as staff did not consistently relay full assessment findings to the physician, which was necessary for determining appropriate interventions. The resident continued to experience pain and abdominal symptoms, and ultimately was found unresponsive and pronounced deceased after resuscitative efforts. The facility's policy required thorough assessment and physician notification for abnormalities, but these steps were not followed, resulting in the deficiency.
Incomplete Documentation During Change of Condition Event
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident who experienced a change of condition (COC) related to constipation, abdominal pain, and other gastrointestinal symptoms. The resident, who had a history of psychosis, muscle wasting, and atrophy, reported not having a bowel movement for two days and complained of abdominal pain, bloating, and discomfort. Despite these complaints and observable symptoms such as abdominal distention and severe pain, the medical record lacked full assessments and documentation of the resident's condition during the COC event. Multiple entries in the resident's medical record, including the Medication Administration Record (MAR), Progress Notes (PN), and SBAR forms, were incomplete or missing critical information. For example, the MAR did not reflect the resident's pain, and the SBAR forms omitted documentation of abdominal symptoms and pain severity. Nursing staff, including LVNs and RNs, acknowledged during interviews that they failed to document key assessment findings such as pain ratings, abdominal assessments, and the presence of coffee-ground emesis. These omissions were contrary to the facility's policies and procedures, which require objective, complete, and accurate documentation of all changes in a resident's condition and the care provided. The Director of Nursing (DON) confirmed that licensed nurses were expected to perform and document full assessments when a resident experienced a COC, emphasizing that missing documentation could affect resident care and communication among the care team. The facility's policies specifically state that all services, changes in condition, and assessments must be thoroughly documented to facilitate communication and ensure appropriate care planning.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of four residents, as evidenced by several incidents. One resident with end-stage renal disease and anxiety disorder was awakened in the early morning by a loud noise made by an LVN, without the light being turned on, which startled and scared her. The resident, unable to communicate due to her tracheostomy, felt unsafe and experienced increased anxiety as a result. The incident was corroborated by the resident's roommate, who witnessed the event and observed the resident's distress. Another resident, who required maximal assistance for daily activities and had intact cognition, reported that staff did not clean his urinal receptacles, leaving them with urine residue and without proper labeling. The resident expressed feelings of disgust due to the persistent smell and the staff's disregard for his requests to properly dispose of the urine. Staff interviews confirmed that the urinals were not labeled or adequately cleaned, contrary to facility policy. A third resident, admitted for post-fracture care and self-responsible, reported that staff were routinely rude and disrespectful when responding to call lights, often speaking in an unfriendly manner and making loud jokes outside the resident's room while the resident was trying to nap. This behavior made the resident feel unimportant and horrible. Additionally, another resident with metabolic encephalopathy and parkinsonism, who was dependent on staff for all activities of daily living, was observed sitting in a hallway in a short-sleeved shirt and incontinence brief, without pants, compromising her privacy. Staff acknowledged that residents should be fully dressed and covered when out of bed, in accordance with facility policy.
Failure to Provide Required Assistance with Activities of Daily Living Due to Staffing Shortages
Penalty
Summary
A deficiency was identified when the facility failed to provide necessary assistance with activities of daily living (ADLs), such as bathing, dressing, and toileting, to 59 out of 67 sampled residents who were unable to perform these tasks independently. These residents, many of whom had complex medical conditions including respiratory failure and tracheostomy tubes, were documented as requiring substantial or total assistance with ADLs according to their Minimum Data Set (MDS) assessments and care plans. The care plans specifically indicated that staff should provide assistance with ADLs as needed. Interviews with staff revealed that Certified Nursing Assistants (CNAs) were frequently assigned to care for a high number of residents, sometimes up to 14 per CNA, especially during periods of short staffing or when scheduled staff called off. The facility's practice was to assign a dedicated shower nurse to provide showers, but this role was often unfilled or reassigned to cover floor assignments when staffing was insufficient. As a result, scheduled showers and bed baths were routinely missed, and documentation (shower sheets) confirming that showers were provided was often absent. Staff reported that when they were short-staffed, they were unable to provide showers, bed baths, or even regular oral care as required. Residents confirmed that they did not receive showers or bed baths as scheduled, sometimes going weeks without proper hygiene care. They also reported significant delays in response to call lights, particularly during night shifts, with some residents waiting hours for assistance. Review of staffing schedules and shower documentation over a two-week period confirmed multiple instances where no showers were provided due to insufficient staffing and the absence of a shower nurse. The Director of Nursing acknowledged that the facility is required to provide care and showers regardless of staffing levels, and the facility's policy stated that appropriate care and services must be provided for residents unable to perform ADLs independently.
Failure to Provide Sufficient Nursing Staff Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff on 16 out of 45 reviewed shifts in the subacute unit, resulting in unmet care needs for 59 out of 67 sampled residents. These residents, many of whom had complex medical conditions such as respiratory failure, tracheostomy tubes, and ventilator dependence, required substantial or total assistance with activities of daily living, including showering, toileting, and transfers. Despite the facility's policy and facility assessment specifying staffing ratios and the assignment of a dedicated shower nurse, staffing shortages were frequent due to call-offs and unfilled positions, leading to the absence of a shower nurse and increased resident assignments for CNAs. Multiple interviews with staff confirmed that when CNAs were assigned 10 to 14 residents each, or when the shower nurse was pulled to cover other assignments, showers and other personal care tasks were not completed. Staff reported being overwhelmed and unable to provide scheduled showers, bed baths, or even routine oral care as required. Documentation of showers was only possible through completed shower sheets, and when these were missing, there was no evidence that care was provided. Residents also reported not receiving scheduled showers or bed baths, and experiencing significant delays in call light responses, particularly during night shifts when staffing was especially low. A review of staffing records revealed repeated instances where the number of CNAs on duty fell below the facility's stated goals, with some shifts having as few as two or three CNAs for over 50 residents. The facility's own policies and facility assessment outlined specific staffing ratios and the need for a shower nurse, but these were not consistently met. The Director of Nursing acknowledged that care and showers must be provided regardless of staffing levels, and that insufficient staffing should not be an excuse for unmet resident needs.
Failure to Ensure Proper Medication Administration and Timely Delivery
Penalty
Summary
The facility failed to ensure proper medication administration for six residents by not following best practices for medication preparation and administration, not administering medications at their scheduled times, and failing to ensure medication availability. For one resident with rheumatoid arthritis, a scheduled dose of Adalimumab was omitted due to lack of supply, and there was no timely notification to the pharmacy or physician. This resulted in the resident missing a dose and experiencing increased rigidity and pain, as documented in the resident's medical records and personal interview. For several residents with G-tubes, a nurse was observed crushing and mixing multiple medications together in one cup and administering them via G-tube without checking for tube placement or flushing between medications, contrary to facility policy and best practice. The nurse admitted to not following protocol due to being pressed for time after several staff called off, which led to late medication administration for multiple residents. The nurse also acknowledged awareness of the correct procedure but did not follow it due to workload pressures. Additionally, medications for several residents were not administered within the prescribed time frames, as required by physician orders and facility policy. The facility's own policies require medications to be administered within one hour of the scheduled time and for medication supplies to be ordered in advance to prevent omissions. Interviews with staff confirmed that these protocols were not followed, leading to missed and late doses for residents with complex medical needs, including those with epilepsy, hypertension, diabetes, and GERD.
Environmental Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean and safe environment in multiple resident rooms and common areas, as evidenced by direct observations, resident interviews, and record reviews. In four separate rooms, there were persistent issues such as dried reddish-brown stains on privacy curtains, dirty baseboards, unpainted white patches on walls, brownish-gray stains on ceilings and walls near air vents, holes in walls with chipped paint, cracked and peeling linoleum flooring, chipped sinks, corroded faucets, and peeling window tint. These environmental deficiencies were observed by surveyors and confirmed by residents, who reported that some of these issues, including dried blood on privacy curtains and damaged walls, had been present since their admission to the rooms and had not been addressed despite requests to staff. Interviews with staff revealed that the process for identifying and addressing environmental issues was inconsistent and relied heavily on staff noticing and reporting problems in a Maintenance Log. The Maintenance Department did not routinely document which rooms were checked or what specific items were inspected during their rounds. Maintenance staff acknowledged that some repairs, such as painting over patched walls and addressing water stains on ceilings, were overlooked or delayed, and that the department was understaffed. Housekeeping staff also failed to change soiled privacy curtains during deep cleaning due to lack of available personnel, despite recognizing the importance of immediate removal for infection control. Review of facility records, including the Maintenance Department's Checklist and Deep Clean Check off List, showed incomplete documentation of cleaning and maintenance activities. The facility's policy required a safe, clean, and comfortable environment, but the observed conditions did not meet these standards. The deficiencies resulted in an unclean and potentially unsanitary environment for residents, staff, and visitors, as directly observed and reported by those affected.
Failure to Maintain Flooring in Good Repair Creates Safety Hazards
Penalty
Summary
The facility failed to maintain floor tiles in good repair and free from hazards as required by its Maintenance Service policy. During an observation with maintenance staff, surveyors identified multiple areas with holes and cracks in the flooring: a two by 24-inch hole at the doorway of a room in Station 4, a four-inch hole around a drain in a hallway of Station 4, cracks in the floor tiles in the hallway in front of the beauty salon on Station 6, and a three by eight-inch hole at the doorway of a room in Station 6. In an interview, the Administrator acknowledged that these holes indicated the environment was not homelike and could cause staff or residents to have a fall. Review of the facility's policy confirmed that maintenance personnel are responsible for keeping the building in good repair and free from hazards at all times.
Failure to Supervise Resident Smoking and Secure Smoking Materials
Penalty
Summary
The facility failed to follow its policy and procedure regarding resident smoking for one resident by not ensuring supervision while the resident was smoking in the designated smoking patio and by not securing the resident's smoking materials in a locked box or drawer. During an observation, the resident was seen smoking a cigarette on the smoking patio without staff supervision, despite the facility's policy requiring supervision for all residents during smoking, regardless of their alertness or orientation. Additionally, a lighter was found on the resident's bed, indicating that smoking materials were not properly secured as required by facility policy. The resident involved had a history of encephalopathy, respiratory failure, and asthma, and required substantial to maximal assistance with several activities of daily living. Facility records, including the resident's Safe Smoking Assessment and Interdisciplinary Team Conference notes, documented the need for supervision and secure storage of smoking materials. Interviews with facility staff confirmed that supervision and secure storage were expected practices, but these were not followed in this instance, potentially compromising the safety of the resident and others.
Failure to Attach Tab Alarm Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a tab alarm was properly attached to a resident who was at high risk of falls, resulting in the resident falling to the floor. The resident, admitted with conditions including hemiplegia, hemiparesis, type 2 diabetes mellitus, and COPD, had a physician's order for a tab alarm to alert staff of unassisted transfers. Despite this order, the alarm was not attached when the resident fell, and it did not sound to alert staff. Interviews with staff revealed that the alarm was not functioning as intended at the time of the fall. The facility's policy indicated that position-change alarms should not be the sole intervention for preventing falls but should assist staff in identifying patterns. However, the alarm's failure to sound when the resident attempted to get out of bed unassisted suggests a lapse in adherence to this policy. Observations confirmed that the alarm was not properly attached to the resident, and staff interviews indicated awareness of the resident's fall risk and the need for the alarm. The manufacturer's manual emphasized the importance of proper installation and operation of the alarm system, which was not followed in this case.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. Eight dumpsters located behind the facility were found with their lids open, contrary to the facility's policy and procedure for garbage disposal, which mandates that dumpster lids should be kept closed. During an observation and interview with the Director of Food Services and Environmental, it was confirmed that the open lids could allow rodents to enter the dumpsters. This observation was supported by a review of the facility's policy titled 'Food-Related Garbage and Refuse Disposal,' which was last revised in October 2017 and specifies that dumpsters should be kept closed and free of surrounding litter.
Deficient Call Light System in Resident Rooms
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly in 12 out of 29 resident rooms, which could potentially delay care for residents. During an observation and interview, a resident reported that their call light did not work the previous night, and subsequent checks by maintenance staff confirmed that the call lights in several rooms were not operational. Additionally, in one room, the call light was not accessible to the resident, as it was hanging over an enteral feeding pump, making it difficult for the resident to reach. Interviews with the Director of Staff Development and the Director of Nursing highlighted the importance of functioning call lights for resident communication and timely assistance. The facility's policies and procedures, which were reviewed, indicated that maintenance is responsible for ensuring that equipment is safe and operable, and that call lights should be within easy reach of residents. However, these policies were not followed, leading to the identified deficiencies.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by another resident. On February 10, 2025, Resident 3 physically and verbally abused Resident 2. Resident 2, who was admitted with diagnoses including encephalopathy, respiratory failure, and pneumonia, was backing up in the hallway when Resident 3 stood up, swung from behind, and hit Resident 2's shoulder, resulting in an abrasion on Resident 2's left cheek. Resident 3, who has diagnoses including Huntington's disease, epilepsy, and schizophrenia, was noted to have a history of aggressive behavior. Resident 3 was moderately impaired in cognitive skills and required partial assistance from staff for daily activities. On the day of the incident, Resident 3 pushed Resident 2's wheelchair, yelled at Resident 2, and physically assaulted Resident 2, causing a small abrasion on Resident 2's cheek. Interviews with other residents revealed that Resident 3 had a history of yelling threats such as "I'll kill you" and "I'll rip your f-ing head off" at other residents, including Resident 2. Witnesses reported that Resident 3 had previously slapped Resident 2 on the back of the head and shoved Resident 2 while making threatening remarks. The facility's policy on abuse prevention, which states that residents have the right to be free from abuse, was not effectively implemented to protect Resident 2 from these incidents.
Failure to Provide Required PT and OT Services
Penalty
Summary
The facility failed to ensure that a resident received the necessary Physical Therapy (PT) and Occupational Therapy (OT) as outlined in their care plan. The resident, who was admitted with diagnoses including traumatic subarachnoid hemorrhage, acute respiratory failure, and dysphagia, was assessed to have severe cognitive impairment and was dependent on staff for daily activities. The care plan, initiated on February 25, 2025, indicated that the resident had a self-care performance deficit related to limited mobility and range of motion, with a goal to maintain their current level of function. The interventions included evaluations and treatments by PT and OT, which were not provided as planned. The Director of Rehabilitation confirmed that the resident's initial evaluations for PT and OT, dated November 15, 2025, recommended treatment six times a week for four weeks. However, the resident only received one session of each therapy due to a lack of insurance authorization. The Director of Nursing stated that the care plan should address all the resident's needs, and if PT and OT were indicated, they should have been provided. The facility's policy on comprehensive, person-centered care plans requires measurable objectives and timetables to meet the resident's needs, which were not implemented in this case.
Deficiencies in G-Tube Care for Two Residents
Penalty
Summary
The facility failed to provide proper care and treatment for two residents with gastrostomy tubes (G-tubes). For Resident 4, the head of the bed (HOB) was not elevated to the required angle of 30-45 degrees during enteral feeding, as observed during a visit. The Licensed Vocational Nurse (LVN) present acknowledged the HOB was not raised high enough and admitted there were no markings on the bedframe to determine the correct angle. The Director of Nursing (DON) confirmed that the HOB should be raised to 35-45 degrees during enteral feeding, as per the facility's policy. For Resident 8, the facility failed to flush the G-tube with water between administering multiple medications. During a medication administration observation, LVN 2 did not flush the G-tube between the second, third, and fourth medications, contrary to the facility's policy which requires flushing with 15 mL of warm purified water between medications. The DON stated that flushing is necessary to aid medication absorption and prevent clogging of the G-tube. Both residents were severely impaired in cognitive skills and dependent on staff for daily activities.
Failure to Provide Prescribed Therapy Services
Penalty
Summary
The facility failed to provide necessary Physical Therapy (PT) and Occupational Therapy (OT) services to a resident as outlined in their care plan. The resident, who was admitted with diagnoses including traumatic subarachnoid hemorrhage, acute respiratory failure, and dysphagia, was assessed to have a good rehabilitation potential. The care plan required PT and OT six times a week for four weeks, but the resident only received one session of each therapy. The deficiency occurred because the facility was waiting for insurance authorization to proceed with the therapy services, which was not received. Despite the evaluations indicating the resident would benefit from PT and OT, and the care plan specifying the need for these therapies, the services were not provided. The Director of Rehabilitation confirmed the resident's need for therapy, and the Director of Nursing stated that therapy should be provided based on evaluations and care plans, regardless of insurance authorization. The facility's policy required assessments and therapy evaluations to determine the need for rehabilitative services. However, the failure to provide the prescribed therapy services as per the care plan potentially impacted the resident's ability to attain, maintain, or restore their highest practicable level of well-being. The policy outlined that therapy services should be initiated based on evaluations and physician orders, but this was not followed in this case.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely reporting of abuse allegations. A housekeeper observed a certified nursing assistant (CNA) sitting on a resident's bed and allegedly pulling the resident towards them. Despite witnessing this incident, the housekeeper did not report it immediately due to nervousness and concern for the CNA. This delay in reporting was contrary to the facility's policy, which mandates immediate reporting of any suspected abuse to the administrator and relevant authorities. Additionally, the facility did not report the abuse allegation to the California Department of Public Health (CDPH) within the required two-hour timeframe. The administrator acknowledged that the facility's protocol was to file a report within two hours of an abuse allegation and to continue the investigation for five days. However, the report was not filed because the resident denied the allegation during the investigation. This failure to report in a timely manner compromised the safety of the resident and exposed them to potential further abuse.
Failure to Complete Neurological Assessments and Monitor Covid-19 Positive Resident
Penalty
Summary
The facility failed to provide necessary care and services for three residents as per its policies and procedures. For two residents involved in a resident-to-resident altercation, the facility did not ensure that licensed nurses completed the required 72-hour neurological assessments. Resident 1, who had schizophrenia and dementia, was struck by another resident, resulting in lower lip discoloration. Despite the care plan and interdisciplinary team recommendations for 72-hour monitoring, the neurological assessment flowsheet was incomplete, missing documentation on pain responses and motor function assessments. Similarly, Resident 2, who had type 2 diabetes mellitus and major depressive disorder, was involved in the same altercation and sustained left under-eye discoloration. The neurological assessment flowsheet for Resident 2 was also incomplete, and the resident reported that nurses were not performing neuro checks. The Director of Nursing confirmed the importance of these assessments to identify any abnormalities and stated that the documentation should have been complete. Additionally, the facility failed to monitor and document the condition of Resident 13, who tested positive for Covid-19 and was transferred to the facility's red zone. The progress notes lacked documentation of the resident's condition over several shifts, despite the requirement for monitoring and documentation every shift for residents with a change in condition. This lack of documentation persisted until the resident exhibited symptoms of chest congestion and difficulty breathing, leading to a transfer to a hospital.
Residents Exposed to Cigarette Smoke Due to Staff Smoking Near Windows
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, as per the facility's policy and procedure titled 'Homelike Environment.' The deficiency was identified when it was observed that the residents were exposed to the odor of cigarette smoke from facility staff smoking outside their room window. This exposure prevented the residents from keeping their room window open to enjoy fresh air, which was important to them. Resident 2, who was admitted with diagnoses including left hemiparesis, hemiplegia following a cerebral infarction, and chronic obstructive pulmonary disease, was dependent on staff for mobility and valued fresh air. Resident 3, admitted with hyperlipidemia, hypertension, and generalized anxiety disorder, also required assistance with mobility and valued fresh air. Both residents had intact cognition and did not currently use tobacco. They expressed that the smell of cigarette smoke bothered them and prevented them from enjoying fresh air through their window. Observations confirmed that the designated employee smoking area was located outside the residents' room window, and staff were seen smoking there, causing smoke to enter the residents' room. The Director of Nursing acknowledged that this situation could expose the residents to secondhand smoke and affect their ability to keep their window open for fresh air. The facility's policies on smoking and maintaining a homelike environment were reviewed, indicating that smoking should not create hazardous or unsafe conditions and that residents should be provided with a pleasant environment, free from unpleasant odors.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call bell for a resident with left-sided hemiparesis was within reach, as required by the facility's policies and procedures. The resident, who was admitted with diagnoses including hemiparesis and hemiplegia following a stroke, was unable to reach the call bell when it was placed on their left side, which was affected by the stroke. This issue was observed during an interview and record review, where the resident and their responsible party confirmed the difficulty in reaching the call bell, leading to challenges in obtaining assistance when needed. The resident's roommate and a Licensed Vocational Nurse (LVN) also confirmed that the call bell was often placed on the resident's left side, making it inaccessible. The Director of Nursing acknowledged that the call bell should have been placed on the resident's right side to ensure accessibility. The facility's policies on accommodating resident needs and answering call lights emphasize the importance of making call bells accessible to residents, which was not adhered to in this case.
Latest citations in California
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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