Kit Carson Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, California.
- Location
- 811 Court Street, Jackson, California 95642
- CMS Provider Number
- 056198
- Inspections on file
- 38
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 69
Citation history
Health deficiencies cited at Kit Carson Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence on staff for dressing was observed lying in bed asleep with no lower body clothing or covering, wearing only an incontinent brief that was visible from the hallway and through a large window with raised blinds. Two LNs acknowledged the resident’s lower body was uncovered and visible, and one identified this as a dignity issue while the other stated the resident should have been provided with lower body clothing. A CNA confirmed the resident was forgetful, needed help with dressing, and emphasized the importance of proper clothing for dignity, while the DON stated residents were expected to be properly dressed to maintain dignity and privacy. These conditions conflicted with facility policies requiring staff to treat residents with dignity, respect, and to protect bodily privacy.
A resident with multiple chronic conditions, including angina, progressive MS, and heart failure, activated a call light after finishing lunch to request removal of a meal tray, but staff did not respond for more than 25 minutes. During this time, the corridor call light remained illuminated while staff were present in the nurse’s station and in the hallway. A CNA initially acknowledged the light but did not respond because the resident was not on her assignment, and another CNA later confirmed the light and entered the room. An LN and the DON both stated that staff are expected to respond to call lights within a few minutes, and facility policy requires call lights to be answered within 3–5 minutes, which did not occur in this case.
A resident with an anxiety disorder had a lorazepam order written for morning and bedtime dosing, but nursing staff routinely scheduled and administered the medication at 3 PM based on the resident’s request without obtaining a corresponding MD order. On one occasion, an LN accidentally locked the medication cart keys inside the cart, resulting in the resident’s scheduled 3 PM lorazepam dose being given at 4:49 PM, outside the facility’s 1-hour administration window. The resident became visibly upset and reported needing the medication at a specific time to control anxiety, while the DON and DSD confirmed that medications must be given according to written MD orders and within the prescribed time frame.
A resident with constipation, muscle weakness, and CKD experienced repeated periods without documented BMs, frequent foul‑odor stools, abdominal pain, intermittent diarrhea, and decreasing oral intake. CNAs reported these issues to nurses, but there was no documentation of nursing assessment, bowel regimen initiation, or physician notification despite facility expectations. Over several days the resident’s ADLs declined from independent showering to needing assistance with showers, dressing, and transfers, with abdominal tenderness and low diastolic BP, yet staff treated this as non‑emergent, did not obtain fresh VS, and relied on a written note in a communication binder rather than direct MD contact. Later, when the resident had diarrhea and lay in a fetal position holding her abdomen, the IP obtained an order for PRN Imodium but did not perform a full abdominal or pain assessment, did not update VS, did not communicate the full presentation to the MD, and the first dose was delayed until the next day. Weekly summary assessments were missed for multiple weeks, and RNs did not complete or sign off on change‑of‑condition assessments as required, contributing to inadequate monitoring and escalation of the resident’s worsening condition.
A facility failed to maintain sufficient CNA staffing and timely call-light response when two scheduled CNAs, both from a registry, were unavailable for an evening shift and no replacements were secured. A resident with bowel incontinence and dependence for toileting activated the call light after becoming soiled and reportedly waited about two hours before an unassigned CNA responded, finding the resident crying, soiled, and with red skin. Staffing records showed one CNA called off and another left early without returning or clocking in/out, and there was no documentation of reassigned CNA coverage for the affected rooms. Staff interviews described unanswered call lights and reliance on registry staff, while facility policies required sufficient and competent staffing, call-light response within 3–5 minutes, adherence to protocols by registry staff, and treatment of residents with dignity and respect.
A resident with diabetes, dysphagia, and orders for a pureed diet with nectar‑thick liquids and a CCHO plan had a jar of peanut butter and jelly at the bedside and reported eating it directly from the jar because he disliked facility food. Nursing staff and a CNA knew the resident sometimes ate peanut butter and jelly and was non‑compliant with his diet but did not recognize or act on the conflict with his ordered pureed/nectar‑thick, CCHO diet or his aspiration precautions. The CDM and ST were unaware the resident was consuming peanut butter and jelly and had not evaluated its safety or appropriateness, while the resident’s significant other stated she had been bringing it for months after being told she could bring any food. The facility’s policy requiring interdisciplinary review and documentation when resident food preferences conflict with prescribed diets was not followed, resulting in ongoing access to food inconsistent with the physician’s orders.
A resident with a history of venous thrombosis and embolism, and intact cognition, had a standing order for Xarelto 20 mg daily at 5:00 PM. On one evening, a registry nurse could not initially locate the medication, and the dose was ultimately given at 6:43 PM, outside the facility’s one-hour before/after administration window. Review of the EMAR, Medication Audit Report, and progress notes showed no documentation explaining the delay, and there was no recorded notification of the physician or pharmacy. This conflicted with facility policies requiring timely administration per MD orders, proper medication storage and access, registry staff competency in medication procedures, and documentation and provider notification when a medication error occurs.
A resident with multiple comorbidities, including HTN, AFib, and CKD, received metoprolol 12.5 mg BID despite repeated low BP readings documented on the MAR. An LN confirmed administering the medication on days with low systolic BP and acknowledged that no specific hold parameters had been obtained from the physician. The DON stated that facility practice was to hold BP meds for HTN when systolic BP was below 110, yet review of the MAR showed metoprolol was given multiple times below this threshold. The resident had no care plan addressing HTN or metoprolol use, including monitoring for adverse effects or its BBW, and the consultant pharmacist’s MRR did not identify or recommend action regarding the missing parameters or low BP readings, preceding a change in condition and hospitalization for very low BP.
A resident with a history of hypertension, pulmonary emboli, and prior stroke had a care plan addressing brief loss of consciousness (LOC), including nursing assessment, monitoring V/S and O2 sats, physician notification, and placing the resident supine with legs elevated. On one morning, the resident experienced an LOC episode during PT; rehab staff laid the resident on a mat but did not obtain V/S, did not position the resident per the care plan, did not secure a nurse assessment, and did not notify the MD, then resumed therapy. Later the same morning, the resident had a second LOC episode in the room; a CNA initially could not obtain BP, an LN briefly entered and left without assessing, and although BP was later obtained and an assessment performed, MD notification was delayed by more than 40 minutes. The DON and DOR confirmed that the resident’s care plan and facility policies on change of condition, nursing assessment, and comprehensive care planning were not followed.
The facility failed to follow its infection prevention and control practices when multiple used towels were left piled on the floor of a shared bathroom for two days. Two residents with multiple cardiac, neurologic, vascular, renal, and endocrine diagnoses shared this bathroom; one resident reported using the towels for personal cleaning and leaving them under the sink, not knowing where to place them and expecting staff to remove them, while the other resident expressed concern he might accidentally use the towels. A CNA, an LN, the IP nurse, and the DON all acknowledged that towels should not be on the floor and should instead be bagged and placed in a soiled laundry bin, consistent with the facility’s IPCP policy requiring a safe, sanitary environment and staff adherence to proper infection control techniques.
A resident with a chronic right lower leg venous ulcer, cellulitis, and diabetes experienced a significant wound decline, with the wound MD observing 100% slough/necrotic tissue, heavy drainage, and excruciating pain. The wound MD urgently recommended hospital admission for operative debridement and the MD gave a verbal order for a vascular surgery consult, but nursing staff did not immediately document or act on these orders, and the vascular referral was not entered for several days. Required 72‑hour change‑of‑condition monitoring with per‑shift VS and pain scores was not initiated or completed, and documentation of the wound MD’s assessment was entered days later without being labeled as a late entry. The TAR showed multiple missed Dakin’s solution treatments, and the wound MD reported finding dry, adherent dressings that suggested daily dressing changes were not being done as ordered. The resident was later transferred to the hospital with septic shock and necrotizing fasciitis of the right leg and died from cardiopulmonary arrest, septic shock, and necrotizing fasciitis.
A resident with diabetes, cellulitis, severe cognitive impairment, and a chronic right lower leg venous ulcer experienced documented worsening of the wound from mixed granulation/slough to 100% slough/necrotic tissue with heavy drainage and severe pain. The WD recommended hospital admission for operative debridement and possible leg amputation, and the WN documented this recommendation and the resident’s pain, but the MD did not review the wound documentation, did not personally reassess the wound, and chose not to send the resident to the hospital at that time. Instead, the MD gave a verbal order for a vascular surgery consult that was not entered into the record for five days, during which only two attempts were made to obtain consent from the responsible party. The resident later showed signs of acute decline, including hypotension, tachypnea, altered responsiveness, and refusal of medications and food, and was ultimately hospitalized with septic shock related to right lower extremity cellulitis and later died; this sequence of events formed the basis of the deficiency for failure of effective physician oversight and timely medical intervention.
A resident with osteoarthritis and dementia experienced an unwitnessed fall and developed persistent moderate to severe L hip pain and marked declines in mobility and weight-bearing ability. Nursing initially notified the MD only of the fall and pain, resulting in a PRN Norco order and a routine x-ray order. Over the following days, PT and OT documented 9–10/10 pain with movement, inability to ambulate or bear weight on the LLE, and increasing assistance needs for bed mobility, transfers, and ADLs, while CNAs reported that the resident could no longer roll in bed, required two-person assist, and cried out in pain during care. The MAR showed frequent Norco use for elevated pain scores, but progress notes contained no evidence that these ongoing changes were reported to the MD. The MD stated he was not informed of the resident’s inability to bear weight, transfer, or walk and ordered the x-ray as routine based on limited information. An eventual x-ray at the hospital revealed a new L hip fracture, and the DON confirmed that the facility failed to report the resident’s prolonged pain and mobility decline to the physician as required by policy.
A resident with Type 2 DM, osteomyelitis, and a chronic left foot ulcer had a physician order for fasting blood sugar checks before breakfast with instructions to notify the physician for BG results above 200 mg/dl and a documented goal for improved BG control. Over a multi-day period, ordered FSBS checks before breakfast were not completed on most days, and one elevated BG value of 256 mg/dl was documented without physician notification or treatment. Interviews with an LN and the DON confirmed the missed FSBS checks, the lack of interventions for the elevated BG result, and the absence of care plan interventions to achieve the stated BG control goal, contrary to facility policies and clinical protocols for glucose monitoring and acute condition changes.
A resident who had recently sustained a fall resulting in a left hip and femur fracture, along with conditions such as muscle weakness, kidney disease, and osteoporosis, was re-admitted to the facility without a fall awareness or fall prevention care plan in place. Despite facility policy requiring evaluation, management, and documentation of interventions for residents at risk for falls, and staff acknowledgment that a fall care plan is part of post-fall protocol and necessary to guide care, the resident’s clinical record contained no fall care plan, leaving staff without documented guidance for fall prevention.
Two residents' rights to privacy were violated when CNAs took unauthorized photographs of them and their rooms using personal phones, without obtaining consent from the residents or their responsible parties. One resident, who had a colostomy bag, was photographed in a compromised state, and another resident was photographed despite being unable to provide consent. These actions were in direct violation of facility policy regarding resident privacy and dignity.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs.
The facility did not ensure that the most recent federal survey results were accessible to residents, family members, or legal representatives. Residents were unaware of where to find the survey results, and staff, including the IP and ADM, could not locate the survey results binder, which was supposed to be by the front door but was missing during inspection. The DON confirmed that without the binder, residents could not review the survey findings or know what the facility was addressing.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not maintain a working call light system, resulting in residents' requests for assistance not being promptly communicated to staff. Staff and administration confirmed the system had not provided audible or visual alerts at the nurses' station for over a year, leading to multiple instances where call lights were left unanswered for extended periods. Facility policy required timely response to call lights, but observations showed this was not met due to the system's failure.
A resident was administered psychotropic medications without clear medical necessity or was given medications that restrained their ability to function, resulting in a deficiency related to medication management.
Two residents were placed at risk when one was left smoking unsupervised without an updated smoking assessment, and another was on oxygen therapy without required 'oxygen in use' signage posted at the room entrance. Staff failed to follow facility policies regarding supervision and safety assessments.
A resident with a history of hypertensive heart disease and heart failure was given Midodrine on seven occasions despite physician-ordered parameters to hold the medication if systolic blood pressure was above 120 mmHg. Nursing staff confirmed the medication was administered in error and that required documentation and notifications were not completed, as per facility policy.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Menus were not consistently prepared in advance, followed, updated, or reviewed by a dietician, resulting in residents' nutritional needs not being met as required.
The facility did not provide or document required education on the benefits and potential side effects of the COVID-19 vaccine for three residents prior to vaccine administration, as confirmed by the Infection Preventionist and review of immunization records. This omission was not in accordance with facility policy, which requires education and documentation before vaccination.
A resident with a urinary catheter was found with their catheter drainage bag exposed and not covered by a dignity bag, contrary to facility policy and staff expectations. Staff interviews confirmed that the privacy cover should have been in place to protect the resident's dignity and privacy.
A resident with cerebral infarction and vascular dementia had conflicting end-of-life treatment preferences documented, with both DNR and Full Treatment marked on the POLST form and in the electronic medical record. Nursing staff and the DON confirmed the inconsistency, and the resident's representative clarified that no resuscitation or life-prolonging measures were desired. The facility's process for reviewing POLST forms failed to identify and correct the error.
A resident was subjected to physical restraints that were not required for medical treatment, in violation of regulations that mandate residents remain free from unnecessary restraints.
A resident with chronic heart failure was receiving oxygen therapy, but staff failed to develop a care plan for this intervention. Both nursing staff and the DON confirmed that no care plan was created, despite facility policy requiring comprehensive, measurable care plans for all residents. This omission resulted in a lack of documented goals and interventions for the resident's oxygen use.
Two residents prescribed antipsychotic medications did not have their required quarterly AIMS assessments completed, as confirmed by record review and staff interviews. Both residents had complex psychiatric and cognitive diagnoses and had been receiving antipsychotic therapy for several months, but their AIMS assessments were left blank and no other completed assessments were found, contrary to facility policy.
Two residents identified as at risk for dehydration did not have fluids available at their bedside, contrary to facility policy and their care plans. Staff confirmed the lack of fluids and observed signs of dehydration, including dry mucous membranes, chapped lips, dry skin, and concentrated urine. The DON stated that fluids should always be available and within reach, and that CNAs are responsible for providing fresh fluids each shift and with meals.
Two residents did not receive proper pharmaceutical services when one did not receive a physician-ordered PRN inhaler due to pharmacy unavailability, and another received an IV antibiotic from the E-kit without required documentation of its removal. Staff interviews and record reviews confirmed that established procedures for medication follow-up, communication, and emergency kit documentation were not followed, resulting in medication unavailability and incomplete records.
Two residents did not receive meals in accordance with their documented dietary requirements and preferences during a lunch service, with one not receiving the specified milk and another being served a disliked food item, despite facility policies and staff expectations to honor such preferences.
Two residents with significant nutritional and physical needs were not provided with the specialized eating utensils indicated on their meal tickets during a lunch meal. Despite documentation and physician orders for adaptive devices, kitchen staff delivered regular utensils, and staff interviews confirmed the omission was not in line with facility policy or care plans.
A resident received the pneumococcal vaccine without documented education on its benefits and potential side effects. The Infection Preventionist confirmed that education should be provided and documented prior to vaccination, but the resident's record lacked this evidence, resulting in a violation of the resident's right to make an informed choice.
Two residents with dementia and a history of wandering were not consistently monitored as required, with missed documentation of Wander Guard device checks and overdue elopement risk assessments. One resident exited the facility unsupervised and was found outside, with no follow-up documentation or reassessment completed. Weekly checks of the Wander Guard system were also not documented, despite being performed.
A resident with osteoporosis and muscle weakness was transferred from a shower chair to bed by a CNA using a one-person 'bear-hug' technique instead of the required two-person assist with a gait belt, resulting in a fractured rib. The resident's care plan and MDS indicated the need for substantial assistance, but the transfer was performed alone and without proper equipment, contrary to facility policy and staff training. Staff interviews revealed a lack of clear documentation and confusion about transfer requirements, contributing to the incident.
A resident with multiple sclerosis was physically abused by another resident with severe mental illness and violent behavior. The attacking resident entered the victim's room and struck him multiple times, causing injuries. Despite a history of violence, the facility failed to provide adequate supervision, leading to the incident. Staff and other residents expressed fear, and the facility's administrator did not classify the attack as abuse, contrary to policy.
The facility failed to ensure full-time onsite supervision by a Dietary Supervisor (DS) and adequate oversight by a Registered Dietitian (RD) for food and nutrition services. The DS worked only three days a week, leaving the kitchen unsupervised on other days, while the RD's limited presence focused on clinical duties, resulting in potential lapses in meal distribution and sanitation for 81 residents.
The facility failed to meet food safety standards, with wet-stored utensils, expired and mislabeled food, and unclean equipment. Observations included spoiled produce, improperly thawed meat, and unmonitored resident refrigerators. Staff lacked knowledge in food cooling and dishwashing processes, highlighting significant training needs.
The facility failed to maintain a clean environment by not securing one of the garbage disposal bins near the kitchen, leaving trash exposed. The Dietary Supervisor and Registered Dietitian acknowledged the importance of keeping lids tightly closed to prevent pest infestations. Facility policy and the FDA Food Code require sealed, tightly closed containers for food waste to avoid nuisances.
The facility failed to conduct interdisciplinary care conferences for several residents, as required by policy. Residents reported not attending these meetings, and record reviews showed incomplete documentation. The Social Services Director admitted to not scheduling these conferences, and other staff confirmed they did not participate in coordinated care planning. The facility's policy mandates these meetings to ensure comprehensive care, but this was not followed.
A facility failed to ensure accurate documentation of end-of-life wishes for six residents, leading to discrepancies between POLST forms and physician orders, and missing Advance Directives in medical records. This resulted in confusion among staff about residents' treatment preferences during emergencies.
The facility failed to maintain professional standards by not consistently completing glucometer QC tests and leaving a resident's medication unattended. The glucometer logbook lacked necessary entries, and a resident's medication was left on their bedside table, contrary to facility policy. These actions risked inaccurate glucose tests and medication errors.
The facility failed to ensure safe pharmaceutical services, including undocumented destruction of non-controlled medications, mismanagement of emergency kits, and inconsistent signing of drug delivery manifests. Additionally, there was a discrepancy in the documentation of narcotic medication for a resident, with the Controlled Drug Record not matching the Medication Administration Record.
A facility failed to monitor vital signs according to physician orders for residents on high-risk medications. One resident received blood pressure medications despite low systolic readings, another was transferred to the ER after receiving heart medications with low blood pressure, and a third received heart medications despite low pulse readings. Staff interviews revealed non-compliance with the facility's medication administration policy.
The facility failed to ensure safe use and monitoring of psychotropic medications for three residents. Non-pharmacological interventions were not documented, and PRN medication use continued beyond 14 days without proper assessment. Interdisciplinary team meetings did not address mental health issues effectively, leading to deficiencies in care.
The facility failed to ensure safe storage and handling of medications and supplies, with issues including a frosted refrigerator, expired glucometer solutions, unlocked emergency kits, and improper handling of hazardous drugs. Staff were unaware of safety protocols, leading to potential risks for residents.
Failure to Maintain Resident Dignity and Bodily Privacy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with dignity and respect and that bodily privacy was maintained. A resident with multiple medical conditions, including congestive heart failure, type 2 diabetes mellitus, chronic pancreatitis, muscle weakness, stage 3 chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, had a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognition. The resident’s documentation showed total dependence on staff for dressing across all shifts, including the morning of the day of the observation. Despite this dependence, the resident was found in bed sleeping with no lower body clothing or covering, leaving only an incontinent brief exposed. During a concurrent observation and interview with two licensed nurses, the resident was visible from the hallway through the open entrance door, and the bed was positioned next to a large glass window with the blinds raised, allowing visibility from outside the room. Both nurses acknowledged that the resident’s lower body was uncovered and that the resident could be seen from the hallway and from outside, and one nurse identified this as a dignity issue while the other stated the resident should have been provided with lower body clothing. A CNA reported that the resident was forgetful, needed help with dressing, and that providing proper clothing was important for dignity and self-respect. The DON stated that residents were expected to be properly dressed to maintain dignity and privacy. These observations and interviews were inconsistent with the facility’s written policies on Resident Rights and Dignity, which require staff to treat residents with kindness, respect, and dignity, to protect bodily privacy, and to avoid demeaning practices that compromise dignity.
Failure to Respond Timely to Resident Call Light
Penalty
Summary
The deficiency involves staff failing to respond in a timely manner to a resident’s activated call light. The resident had been admitted with multiple diagnoses, including angina pectoris, non-active primary progressive multiple sclerosis, hypertensive heart disease with heart failure, osteoarthritis, muscle weakness, muscle spasm, headache, and chronic pain. On the day of observation, the resident reported that lunch was delivered at 12:00 PM and finished by 12:15 PM, but the meal tray remained in place on the overbed table. The resident stated he activated the call light to request assistance with removing the tray and had been waiting approximately 10 minutes before the surveyor’s initial observation. Surveyors observed the corridor call light above the resident’s door illuminated while two staff members were seated in the nurse’s station. Over the course of multiple observations, the call light remained on for more than 25 minutes. A CNA in the hallway acknowledged the call light but stated the resident was not assigned to her. Another CNA confirmed the call light was activated and that the resident was the only one on that side of the hall assigned to her, then entered the room and turned off the call light. The LN at the nurse’s station acknowledged that the call light had been on for more than 25 minutes and not answered in a timely manner, despite the facility’s expectation that any staff respond within a couple of minutes. The DON stated staff were expected to answer call lights as soon as possible, within three to five minutes. The facility’s written policy indicated call lights should be answered within a reasonable time of three to five minutes, which was not followed in this instance.
Failure to Follow Physician Lorazepam Order and Timely Administration
Penalty
Summary
The facility failed to ensure professional standards of pharmacy services were met for one resident when the physician’s lorazepam order and the actual administration schedule did not match, and when a scheduled dose was administered significantly late. The resident, who had an anxiety disorder, was admitted with a diagnosis that included anxiety and had an order on the Medication Administration Record (MAR) for lorazepam to be given by mouth every morning and at bedtime for manifested anxiety related to the anxiety disorder, with administration times documented as 3 AM and 3 PM. Interviews with nursing staff revealed that, despite the written order indicating administration at bedtime, the lorazepam was routinely scheduled and given at 3 PM per the resident’s request, without a corresponding physician order to change the time. The Director of Staff Development stated that medication orders must include the resident’s name, date, medication name, dose, frequency, and physician signature, and that medications should be administered per the time frame ordered by the physician. On one occasion, the resident reported that the licensed nurse locked the keys inside the medication cart and could not access the lorazepam dose that was due at 3 PM. The resident stated she did not receive the medication until two and a half hours later and appeared visibly upset, stating she needed the medication at a specific time to control her anxiety. The facility’s Medication Admin Audit Report, reviewed with the Director of Nursing, showed the lorazepam was scheduled for 3 PM but was not administered until 4:49 PM, and the DON confirmed medications should be administered within one hour before or after the scheduled time to ensure therapeutic effect. The nurse involved confirmed she had accidentally locked the keys in the cart and that the lorazepam was administered late, and also confirmed that the medication was scheduled for 3 PM per the resident’s request even though the order indicated bedtime and should not have been given at 3 PM without a physician’s order. Facility policy on medication administration required that drugs be administered in accordance with written physician orders and within one hour before or after the ordered administration time.
Failure to Assess, Monitor, and Notify Physician for Resident With Constipation, Abdominal Pain, and ADL Decline
Penalty
Summary
The deficiency involves the facility’s failure to provide assessment, monitoring, and physician notification consistent with professional standards for a resident with constipation, abdominal pain, and progressive decline. The resident had multiple diagnoses including constipation, muscle weakness, and chronic kidney disease. Bowel movement (BM) records showed repeated periods with no documented BM for 2–6 days over December and January, as well as frequent documentation of foul‑odor stools. CNAs reported that the resident frequently complained of abdominal pain, pointed to her mid‑abdomen, had foul‑smelling stools, and experienced intermittent diarrhea, nausea, and decreased oral intake, and that these concerns were reported to nurses. The DON confirmed that there was no documentation that nurses assessed the resident, notified the physician, or implemented a bowel regimen when the resident went multiple days without a BM or when foul‑odor BMs were recorded, despite facility expectations and standing bowel regimen orders. The resident also experienced a progressive decline in ADLs and mobility that was not appropriately escalated. On one date, an SBAR documented that the resident reported feeling too weak to shower independently, had lower back and abdominal pain, decreased mobility, and abdominal tenderness, with a blood pressure of 116/48. Nursing progress notes over the next two days documented that the resident went from needing help with showers only to needing assistance with dressing and then transfers, indicating increasing weakness. The nurse categorized this as a non‑emergent change, placed a written note in a communication binder instead of directly calling the physician, and did not obtain a fresh set of vital signs at the time of the change in condition. The physician’s late‑entry progress note for a visit the next day did not address the ADL decline or abdominal tenderness, and there was no documentation that the physician had been directly informed of these changes. The DON stated that such ADL decline and abdominal tenderness should have been reported to the physician right away and that the SBAR did not reflect the full extent of the resident’s progressive decline. On another date, the Infection Preventionist completed an SBAR for the resident’s diarrhea but did not perform a comprehensive assessment or fully communicate the resident’s condition. The SBAR documented that the resident had diarrhea twice a day and was lying in a fetal position holding her stomach, but the IP reported that he only informed the physician about the diarrhea and request for medication, not the fetal position or abdominal holding. He did not obtain new vital signs, did not palpate the abdomen, did not auscultate bowel sounds, and did not assess pain, and he entered earlier vital signs into the SBAR instead. The IP obtained an order for PRN Imodium but did not administer the first dose, stating he believed he endorsed it to the oncoming nurse; the medication was first given the next morning. Meal intake records showed the resident repeatedly refused or minimally consumed meals over several days, but there was no nursing documentation of assessment related to decreased intake. The DON stated that repeated meal refusals or decreased intake over multiple days should be reported to the nurse and then to the physician. Additionally, required weekly summary assessments and RN involvement in change‑of‑condition assessments were not completed as expected. The DON verified that weekly summary assessments were missing for multiple weeks in December and January and all of February, even though they were expected every Wednesday. These weekly summaries were described as comprehensive assessments of weight, skin, mental status, bowels, eating, ADLs, medications, and fluids, and as a means of monitoring for changes that would trigger a change‑of‑condition evaluation and physician notification. The DON also confirmed that SBARs for the resident’s changes in condition on two key dates were completed by an LVN, with no documentation that an RN assessed the resident or signed off, despite the facility’s stated practice that an RN should assess residents after a change in condition. Hospital records later documented that the resident presented with several weeks of abdominal pain, diarrhea, and increasing weakness, was found to have colitis with possible microperforation and significant constipation, and ultimately had a perforated sigmoid colon with fecal contamination, septic complications, and death.
Failure to Maintain Sufficient CNA Staffing and Timely Call-Light Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff were available on a specific evening shift, resulting in unmet care needs for a resident who was fully dependent on staff for toileting and hygiene. On that evening, two CNAs who were scheduled to work were unavailable: one CNA called off for the shift, and another CNA, a registry staff member, left early and did not return. No replacement staff were secured for either CNA, and the facility was unable to produce accurate documentation of how CNA assignments were regrouped or redistributed after these staffing losses. As a result, there was no documented reassignment for the resident care groups that included the affected resident’s room. The resident involved had diagnoses including constipation and Ogilvie syndrome and was documented as always incontinent of bowel and dependent for toileting and hygiene per the MDS Section GG and Section H. The resident was cognitively intact, with a BIMS score of 14, and resided on Station 1. On the evening in question, the resident reported becoming soiled due to her medical condition and activating the call light for assistance. She stated that the registry CNA assigned to her care left early and did not return, and that she waited approximately two hours after activating the call light before receiving help. During an interview and observation, the resident became teary while recounting the event and explained that managing her uncontrollable bowel movements was difficult. Multiple staff interviews and record reviews corroborated the staffing and response issues. Review of the NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET confirmed that one registry CNA called in and another registry CNA signed in for the shift but left early and did not clock in or out, with no replacement staff identified. The DSD, IP, and Human Resources/Maintenance Director confirmed there was no documentation of revised CNA assignments for the affected resident groups after the staffing changes. Staff, including a CNA who was not assigned to the resident, reported that call lights were not consistently answered that evening and that multiple call lights were observed unanswered. This CNA responded to the resident’s call light, found the resident crying and in a soiled brief, and observed that the resident’s skin appeared red when she was changed. Facility policies reviewed indicated that staffing should be sufficient and competent to meet resident needs, call lights should be answered within 3–5 minutes, registry staff should follow facility protocols and documentation requirements, and residents should be treated with respect, kindness, and dignity.
Failure to Control Off‑Diet Peanut Butter and Jelly for Resident on Pureed, Nectar‑Thick, CCHO Diet
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food available to a resident was consistent with the physician‑ordered pureed diet with mildly thick (nectar‑thick) liquids and a consistent carbohydrate (CCHO) plan. The resident had multiple diagnoses, including diabetes mellitus, anemia, atrial fibrillation, acute respiratory failure with hypoxia, and chronic kidney disease, and was on aspiration precautions with safe swallowing instructions posted at the bedside. Despite these orders and precautions, surveyors observed a jar of Smucker’s Goober Strawberry Peanut Butter & Jelly Stripes on the resident’s bedside table within reach. The resident reported that he did not like the pureed food served by the facility, acknowledged having difficulty swallowing, and stated that he had been eating peanut butter and jelly directly from the jar since the previous year without being told it could be unsafe. Nursing and CNA staff were aware that the resident was sometimes non‑compliant with the prescribed diet and had seen him eating peanut butter and jelly, but they did not recognize or act on the potential conflict with his ordered pureed/nectar‑thick, CCHO diet. The LN confirmed the resident’s diet order and aspiration precautions, acknowledged seeing him eat peanut butter and jelly, and admitted uncertainty about whether it was safe. The CNA stated that the resident did not like the pureed food, had observed him eating peanut butter and jelly as a snack, and knew he was sometimes non‑compliant with his diet, but was not aware of his swallowing precautions and did not know that peanut butter and jelly could be unsafe for him. Neither staff member reported the issue through the facility’s processes or sought further assessment of the resident’s swallowing in relation to this food. The dietary and therapy departments were also not informed of the resident’s ongoing consumption of peanut butter and jelly. The Certified Dietary Manager, upon review of the electronic health record, confirmed the resident’s CCHO diabetic dysphagia diet with pureed texture and nectar‑thick liquids and stated that peanut butter and jelly did not meet the physician‑ordered diet due to both texture and sugar content. The Speech Therapist reported that she had not evaluated the resident for some time, was unaware that he was eating peanut butter and jelly directly from the jar, and had never assessed his ability to safely swallow that food. The resident’s significant other stated that she had been bringing peanut butter and jelly for about three months, that staff had told her she could bring any food she wanted, and that she continued to bring it because the resident would not eat otherwise, despite being aware there could be safety concerns. The facility’s policy on resident food preferences required the dietitian and nursing staff, with physician involvement, to address conflicts between resident preferences and prescribed diets, but this process was not implemented in relation to the resident’s peanut butter and jelly consumption. Overall, the facility did not ensure that the resident’s available food was consistent with the ordered pureed, nectar‑thick, CCHO diet, did not communicate or coordinate among nursing, dietary, and therapy staff regarding the resident’s off‑diet food brought by family, and did not follow its own policy for managing resident food preferences that conflict with prescribed diets. This resulted in the resident having independent access to and consuming peanut butter and jelly that did not conform to his physician‑ordered diet and swallowing precautions.
Late Administration of Anticoagulant by Registry Nurse Without Documentation
Penalty
Summary
The deficiency involved the facility’s failure to ensure a prescribed anticoagulant was administered within the facility’s established time frame and in accordance with professional standards of practice. A resident with a history of venous thrombosis and embolism, and with intact cognition as evidenced by a BIMS score of 14/15, was ordered Xarelto 20 mg daily at 5:00 PM. On the evening in question, the resident reported that a registry nurse assigned to her was unable to find her Xarelto, and that it took some time before the medication was administered. Review of the EMAR and Medication Audit Report showed that the Xarelto dose scheduled for 5:00 PM was actually administered at 6:43 PM, which exceeded the facility’s acceptable administration window of one hour before or after the scheduled time. Record review from 2/19/26 to 2/24/26 revealed no documentation explaining the reason for the delayed administration of Xarelto on that date. During interviews, the DON and Infection Preventionist confirmed that the administration time was 43 minutes beyond the acceptable window and acknowledged there was no documentation of the cause of the delay. Both indicated it was likely the registry nurse did not know where to locate the medication. Facility policies required medications to be administered in accordance with physician orders and within one hour before or after the scheduled time, required registry staff to be oriented and competent in facility-specific medication administration procedures, and defined medication errors to include omissions of vital medications, with prompt physician notification and documentation of the error and subsequent orders. Policies also required medications to be stored safely, securely, and properly, with access limited to authorized staff. These requirements were not met in this incident, as the anticoagulant was administered late, the reason for the delay was not documented, and there was no documented notification of the physician or pharmacy.
Failure to Safely Monitor and Administer Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and safe administration of metoprolol for a resident treated for hypertension. The resident was admitted with multiple diagnoses including diabetes mellitus, anemia, atrial fibrillation, acute respiratory failure with hypoxia, and chronic kidney disease. Progress notes documented that on one day the resident had a blood pressure of 100/58, appeared deeply asleep, refused medications and food at lunchtime, and then went back to sleep. The following day, progress notes documented a blood pressure of 86/58, lethargy, slow response, pallor, and that the resident was not responding per baseline, leading to physician contact and transfer to the emergency room. Review of the Medication Administration Record (MAR) showed that the resident had a physician order for metoprolol tartrate 12.5 mg by mouth twice daily for hypertension. The MAR documented multiple low blood pressure readings in January and February, including systolic readings at or near 100 mmHg, on days when metoprolol was administered. A licensed nurse confirmed that she administered metoprolol on days when low blood pressure readings were recorded and acknowledged that when blood pressure medication orders do not include parameters, the nurse should assess the resident, review blood pressure readings, notify the physician, and request clarification for safe parameters. She further stated that if metoprolol had included parameters for holding the medication, the recent change in the resident’s condition that resulted in hospitalization due to very low blood pressure might have been avoided. The DON stated that the facility’s process for administering blood pressure medications included holding parameters based on diagnosis: for residents treated for hypertension, nurses should hold blood pressure medication if systolic blood pressure is less than 110, and for residents treated for heart failure, if systolic blood pressure is less than 100. The DON’s review of the MAR confirmed that metoprolol was administered multiple times when the resident’s systolic blood pressure was below 110, which was not consistent with the facility’s stated process. The DON also confirmed that the resident did not have a care plan addressing hypertension or the use of metoprolol, including monitoring for potential adverse effects and its black box warning. Additionally, the February Medication Regimen Review completed by the consultant pharmacist included the resident but did not contain any recommendations regarding the lack of medication parameters or the documented low blood pressure readings.
Failure to Implement Care Plan After Episodes of Loss of Consciousness
Penalty
Summary
The deficiency involves the facility’s failure to implement an existing care plan for a resident who experienced episodes of brief loss of consciousness (LOC). The resident had multiple significant diagnoses, including hypertension, multiple segmental thrombotic pulmonary emboli, cerebral infarction with aphasia, muscle weakness, and facial weakness. The resident’s care plan, initiated several days prior, identified a focus on episodes of brief LOC and included interventions such as assessing the resident, monitoring for further syncopal episodes, monitoring vital signs (V/S) and O2 saturations, notifying the physician for any change of condition, and placing the resident in a supine position with legs elevated. On the morning in question, the resident experienced a first LOC episode in the rehabilitation room while standing at parallel bars during PT. The PTA reported that the LOC lasted about 30 seconds, during which the resident was laid on a fall mat. Another rehab staff member left to look for a nurse but returned stating that no nurse could be found, and no licensed nurse came to evaluate the resident. Despite a BP machine being available in the rehab room, the resident’s V/S were not taken, O2 sats were not monitored, the resident was not placed supine with legs elevated per the care plan, and the physician was not notified. After the resident regained consciousness, the PTA continued the mat program without a nursing assessment or implementation of the care plan interventions. Later that morning, the resident had a second LOC episode while in a wheelchair in his room, witnessed by a family member and a PTA. After the resident briefly lost consciousness and then attempted to vomit, CNA 1 attempted to obtain BP with a wrist monitor but initially could not get a reading and left to call for a licensed nurse. When LN 1 first entered the room, he stated he had just returned from lunch and left without assessing the resident. CNA 1 then obtained a BP reading several minutes later, and LN 1 returned and assessed the resident, who appeared pale, cold to touch, and sweaty. The family member reported this was the second LOC episode that morning and that no nurse had come after the first episode. LN 1 stated he did not receive notification of the first LOC and acknowledged that physician notification after the second episode was delayed by more than 40 minutes. The DON confirmed that the resident’s care plan interventions for LOC, including nursing assessment, monitoring V/S and O2 sats, physician notification, and placing the resident supine with legs elevated, were not implemented during the first episode and were not timely during the second episode, contrary to facility policies on nursing assessment, change of condition, and comprehensive care plans.
Soiled Towels Left on Shared Bathroom Floor Breach Infection Control Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices when multiple used towels were left on the floor of a shared bathroom used by two residents for two days. One resident, who had diagnoses including nonrheumatic aortic valve stenosis, chronic atrial fibrillation, atherosclerotic heart disease, hypertensive urgency, chronic kidney disease stage II, and dementia, shared the bathroom with another resident diagnosed with cerebral infarction, chronic atrial fibrillation, peripheral vascular disease, hypothyroidism, sick sinus syndrome, and alcohol use. During observation, the shared bathroom door was open, and multiple used towels were piled on the floor under the sink in clear view of one resident lying in bed. That resident reported using the towels for cleaning herself, stated she did not know where to place the used towels, and confirmed they had remained under the sink for two days, expecting staff to pick them up. The other resident stated he did not like used towels on the floor because he might accidentally use them. CNA staff stated they were expected to ensure residents’ rooms were clean and that towels should not be left on the floor, acknowledging that soiled towels on the floor created an infection control concern, especially if another resident used them. A licensed nurse confirmed the presence of the pile of towels on the bathroom floor and stated that soiled towels should be placed in a plastic bag, closed, and then placed in a laundry bin outside the room to prevent contamination and spread of infection. The Infection Prevention Nurse and the Director of Nursing both stated that used towels should not be placed on the floor and should instead be bagged and placed in a soiled bin because they may contain hazardous material and could harbor germs and microorganisms. The facility’s Infection Prevention and Control Program policy indicated that an IPCP is to be established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including educating staff and ensuring adherence to proper techniques and procedures.
Failure to Implement Wound MD and MD Orders, Monitor Change of Condition, and Provide Ordered Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services and to follow professional standards in managing a resident’s worsening right lower leg venous ulcer and associated change in condition. The resident had a history of a non‑pressure chronic ulcer of the right lower leg, cellulitis, and type 2 diabetes, with severe cognitive impairment and a responsible party designated for decision‑making. Weekly skin assessments initially documented the wound as improving, but a later assessment described the wound as worse, with 100% slough/necrotic tissue and heavy drainage. During wound rounds on that date, the wound doctor (WD) observed the deterioration, noted the resident was in excruciating pain despite pre‑medication, and verbally recommended hospital admission for operative debridement above and below a possible leg amputation. The WD communicated this recommendation to the medical director (MD) and the wound nurse (WN), and the MD agreed that the resident needed a higher level of care and a vascular surgery evaluation. Despite this, the facility did not timely implement the WD’s recommendation or the MD’s verbal order. The MD stated he gave a verbal order on the same date for the resident to be seen by a vascular surgeon and expected it to be carried out within 24 hours. However, the vascular surgery referral order was not entered into the medical record until five days later, and the consultation was not arranged before the resident was ultimately transferred to the hospital. The DON confirmed that the WN did not follow the facility’s policy requiring verbal orders to be recorded immediately and acknowledged that the order for vascular consultation was delayed. The WN also documented the WD’s assessment and recommendation as a progress note several days after the event without labeling it as a late entry, and the DON stated this late, unlabeled documentation could cause confusion and was not acceptable practice. The responsible party reported never refusing hospital transfer or raising cost concerns, and described the resident’s rapid cognitive decline and severe leg pain during this period. The facility also failed to initiate and complete required monitoring and wound treatments after the change in condition was identified. The WN and DON both stated that the resident’s worsening wound and severe pain on the date of the WD’s assessment constituted a change of condition that should have triggered 72‑hour monitoring with vital signs and pain assessments every shift. Review of progress notes and the SBAR form showed that this monitoring was not initiated on the date of the change and was not completed every shift for 72 hours. The DON confirmed that vital signs and pain scores were not documented each shift following the change in condition. In addition, the Treatment Administration Record showed multiple missed Dakin’s solution treatments to the right lower leg venous ulcer on several days, and the WD reported that, on weekly visits, the dressings were dry, hard to remove, and stuck to the wound, leading him to question whether daily dressing changes were being performed as ordered. The DON verified the missed treatments and stated this created a risk of wound deterioration. Ultimately, the resident was sent to the hospital with confusion, hypotension, tachypnea, and laboratory evidence of sepsis, was diagnosed with septic shock related to right lower extremity cellulitis and necrotizing fasciitis, and died from cardiopulmonary arrest, septic shock, and necrotizing fasciitis of the right leg.
Failure of Physician Oversight and Timely Response to Worsening Venous Leg Ulcer
Penalty
Summary
The deficiency involves the failure of the Medical Director/attending physician to effectively oversee, supervise, and assess a resident’s medical care in relation to a worsening right lower leg venous stasis ulcer. The resident was admitted with diagnoses including a non‑pressure chronic ulcer of the right lower leg, cellulitis, and type 2 diabetes, and had severe cognitive impairment with a responsible party designated for decision‑making. An order was in place for wound evaluation and treatment by an outside wound care company, and weekly skin assessments documented the wound’s status. On one weekly assessment, the wound nurse documented that the right lower leg venous ulcer measured approximately 15 cm x 5 cm x 0.4 cm post‑debridement, with 50% slough and 50% granulation tissue, significant drainage, no odor, no signs or symptoms of infection, and that the wound was showing improvement. On a subsequent weekly assessment, the wound nurse documented that the same wound was worse, with the same measurements but now 100% slough/necrotic tissue and heavy drainage, though still noted as having no odor and no signs or symptoms of infection. During wound rounds on that later date, the wound doctor evaluated the resident’s right lower leg ulcer, determined that bedside wound care was not effective, and recommended hospital admission for operative debridement and possible above‑ and below‑knee amputation. The wound nurse later entered a progress note reflecting that the wound was worsening, had 100% slough/necrotic tissue, heavy drainage, and that the resident was in excruciating pain despite pre‑medication; this note was entered with a later date but described the earlier wound‑rounds encounter, and the nurse acknowledged she did not label it as a late entry to avoid it being flagged. The care plan for skin integrity was updated to include the wound doctor’s recommendation for hospital admission for operative debridement and possible leg amputation. The Medical Director stated that the wound doctor informed him of serious concern about the resident’s non‑healing venous ulcer, significant vascular compromise, and the need for hospitalization and evaluation by a vascular surgeon. The Medical Director reported that he gave a verbal order to the wound nurse for a vascular surgery consult and expected it to be carried out by the following day, but he did not send the resident to the hospital at that time because he did not feel it was urgent and had not reviewed the wound doctor’s notes or the documented deterioration of the wound. The order for the vascular consult was not entered into the medical record until five days after the verbal order, and the DON confirmed that only two attempts were made to obtain consent from the responsible party for the vascular consult during that period. The Medical Director also acknowledged that he did not assess the resident’s right leg ulcer after the wound doctor’s recommendation and could not recall the last time he personally assessed the wound, stating he had not gone out of his way to observe it because the facility had a wound team. Subsequently, the resident experienced a change in condition, with documentation by the wound nurse of low blood pressure (79/42), elevated respirations (30), slightly elevated temperature (99.6°F), non‑responsiveness compared to baseline, refusal of medications, refusal of breakfast, no fluid intake, facial grimacing with moaning, and refusal of pain medication. The resident was later sent to the hospital, where records showed presentation to the ED with confusion, increased heart rate, and low blood pressure due to septic shock related to cellulitis of the right lower extremity. Hospital findings included markedly elevated WBC, elevated lactic acid, CT evidence of a large soft tissue defect with fluid collection extending to the lateral ankle and forefoot muscles, and positive blood cultures for multiple bacteria. The resident was admitted to the ICU, later placed on comfort measures only, and died with causes listed as cardio‑pulmonary arrest, septic shock, and necrotizing fasciitis. Facility documents describing the Medical Director’s duties included coordinating medical care, participating in patient care review and infection control, being responsible for reviewing and evaluating patient care services, and making skin and high‑risk patient rounds, which contrasted with the Medical Director’s statements that he had not reviewed the wound documentation or assessed the wound after the wound doctor’s urgent recommendation.
Failure to Notify Physician of Resident’s Significant Change in Condition After Fall
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident following an unwitnessed fall, resulting in a left hip fracture going undiagnosed for six days. The resident had a history of bilateral primary osteoarthritis of the left hip and vascular dementia and had been functioning with improving mobility in PT and OT prior to the fall. On the morning of the fall, nursing documentation showed the resident was found on the floor lying on the left side, reported left hip pain at 5/10 with sharp, painful-to-touch discomfort, and had some decreased ability to move the left leg. The nurse notified the physician of the fall and pain, and the physician ordered PRN Norco for moderate to severe pain. The physician later, on a follow-up visit, ordered a routine x-ray of both hips and pelvis and therapy reassessment, with the x-ray appointment scheduled for a later date. In the days following the fall, multiple clinical records documented a marked and ongoing decline in the resident’s mobility and persistent moderate to severe pain with movement, but there was no documentation that these changes were communicated to the physician. PT notes from 2/2 through 2/5 recorded that the resident complained of 10/10 pain with movement of the left lower extremity, was unable to ambulate, could not bear weight on the left leg, and required increasing assistance for bed mobility and positioning, with pain at rest remaining low but pain with movement consistently at 9–10/10. OT notes over the same period documented that the resident repeatedly reported 10/10 pain, refused or was unable to participate in weight-bearing activities, and that left lower extremity pain significantly impacted the ability to perform transfers, toileting, and ADLs, limiting therapy to in-chair ADLs and upper extremity strengthening. Therapy staff confirmed that prior to the fall the resident could fully straighten the left leg, had full ROM, and ambulated 50–60 feet with a FWW and contact guard, but after the fall could not walk, bear weight, extend or move the left leg, or roll in bed without severe pain, and that this information was not documented as being communicated to licensed nurses or the physician. Nursing and CNA interviews further described unreported changes in the resident’s condition. CNAs stated that after the fall the resident was in “quite a bit of pain,” could no longer roll in bed as before, required two CNAs for bed mobility instead of one, could not fully extend the left leg, and cried out in pain and said “please, no” during incontinent care and repositioning; these changes were reported to a licensed nurse. The MAR showed a significant increase in the use of Norco for pain scores ranging from 5/10 to 8/10 after the fall. Progress notes from 1/31 through 2/6 contained no evidence that the physician was notified of the resident’s ongoing severe pain with movement, inability to move in bed, stand to transfer, bear weight, or ambulate. The nurse later acknowledged suspecting a possible dislocation or fracture based on the resident’s increased pain and inability to straighten the leg, and confirmed that therapy and CNAs had reported moderate to severe pain and decreased mobility, but he did not report these ongoing issues to the physician because the PRN Norco was effective in reducing pain and an x-ray was already scheduled. The physician stated he was not informed of the resident’s inability to bear weight, transfer, roll in bed, or walk after the initial report and that he ordered the x-ray as routine based on the limited information provided. The DON confirmed there was no documentation that the resident’s mobility declines and prolonged moderate to severe pain were communicated to the physician, despite facility policies requiring assessment and reporting of signs such as pain, decreased mobility, and other acute condition changes for physician evaluation and management. On 2/6, when the x-ray was finally completed at the acute care hospital, it showed a new left hip fracture. The PT and OT discharge summaries documented a clear decline from baseline and from the functional status on 2/1 to the time of transfer, including progression from minimal or contact guard assistance to maximum assistance for bed mobility, transfers, and functional mobility during ADLs, and the inability to ambulate due to safety concerns. The DON stated that these signs and symptoms—pain, decreased mobility, and functional decline—should have been considered a change of condition and reported to the physician, and confirmed that the lack of such reporting delayed the diagnosis and treatment of the resident’s left hip fracture and caused the resident to experience continued declines in mobility and unneeded pain and suffering.
Failure to Monitor and Respond to Ordered Fasting Blood Glucose Checks
Penalty
Summary
The deficiency involves the facility’s failure to provide care and treatment in accordance with professional standards of practice for a resident with Type 2 diabetes mellitus, osteomyelitis, a non-pressure chronic ulcer of the left heel and midfoot, and cellulitis of the left lower limb. The resident was admitted with these diagnoses, and on 12/24/25 the physician ordered fasting blood sugar (FSBS) checks before breakfast with instructions to notify the physician for blood glucose (BG) results greater than 200 mg/dl. A physician progress note dated 12/30/25 directed that blood glucose levels be monitored closely to support wound healing. The resident’s care plan, dated 12/31/25, included a focus on nausea and vomiting with a goal for better control of blood glucose in 14 days, but there were no interventions documented to address how this goal would be met. Review of the Medication Administration Records (MARs) for 12/1/25 through 12/31/25 and 1/1/26 through 1/31/26 showed that FSBS tests before breakfast were not completed on multiple days after the order was initiated. Specifically, there were no FSBS tests documented before breakfast on 12/24/25, 12/25/25, 12/27/25, 12/29/25, 12/30/25, and 12/31/25, and no FSBS tests documented before breakfast on 1/1/26, 1/2/26, 1/3/26, 1/5/26, and 1/6/26. A blood glucose result of 256 mg/dl was documented on 1/6/26 at 8:30 AM. The facility’s policy on obtaining a fingerstick glucose level required the nurse to record blood sugar results in the medical record and promptly report results outside physician-ordered parameters to the supervisor and physician. During interviews and concurrent record reviews, a licensed nurse confirmed that the resident had an order starting 12/24/25 for FSBS checks before breakfast with instructions to report BG results greater than 200 mg/dl to the physician, and acknowledged that the ordered blood sugar checks were not completed for 11 out of 13 days between 12/24/25 and 1/6/26. The DON confirmed that breakfast trays were delivered between 7:00 AM and 8:00 AM, verified the missing FSBS tests for 11 of 13 days in that period, and confirmed that the elevated BG result of 256 mg/dl on 1/6/26 was not reported to the physician and no treatment for hyperglycemia was administered. The facility’s acute condition changes protocol required staff to monitor and document the resident’s progress and response to treatment so the physician could adjust treatment, but this monitoring and follow-up were not carried out as ordered for the resident’s blood glucose management.
Failure to Initiate Fall Prevention Care Plan After Resident Re-admission With Hip Fracture
Penalty
Summary
Surveyors identified a deficiency in care planning when the facility failed to develop a fall awareness and fall prevention care plan for a resident upon re-admission. Record review showed that on 12/17/25 the resident was found by a CNA lying on her back on the hallway floor, complaining of lower extremity pain, and was sent to the hospital for evaluation. The resident was re-admitted on 12/22/25 with diagnoses including fracture of the left femur, hip fracture, muscle weakness, kidney disease, and age-related osteoporosis. Nursing progress notes documented the re-admission with a left hip fracture diagnosis. During interviews and concurrent record reviews with a licensed nurse and the DON on 1/7/26, both confirmed that the resident’s clinical record did not contain a fall care plan. The licensed nurse stated that a fall care plan was important for resident safety and was part of the facility’s protocol after a fall. The DON stated that the care plan was used by all staff as a guide for resident care and acknowledged that the absence of a care plan meant nursing staff lacked guidance about the resident’s care. The DON also stated she expected staff to have initiated a fall care plan due to the resident’s fall history and risk of falls. Review of the facility’s Falls Management policy indicated that the facility’s process included evaluating, managing, and reducing falls, with licensed nurses documenting interventions and monitoring responses, but this was not implemented for the resident following re-admission.
Failure to Maintain Resident Privacy Due to Unauthorized Photography
Penalty
Summary
Staff members failed to maintain residents' rights to privacy when two certified nursing assistants (CNAs) took photographs of two residents and their rooms using personal phones without obtaining the residents' knowledge or consent. One resident, who was no longer at the facility at the time of review, was photographed in their room by a CNA, despite being unable to provide consent and without the responsible party being informed or asked for consent. The Director of Staff Development (DSD) confirmed that photographs were taken without proper authorization, acknowledging that this action violated the resident's privacy. In another instance, a CNA took photographs of a resident's colostomy bag, which was leaking and dirty, again without obtaining consent from the resident. The photographs were taken on the CNA's personal phone, and the DSD confirmed that consent should have been obtained prior to taking any photographs of the resident or their surroundings. Facility policy requires employees to treat residents with respect, dignity, and to maintain privacy and confidentiality, which was not followed in these cases.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care practices for residents requiring assistance with bowel and bladder management, catheter maintenance, and infection prevention.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the most recent federal recertification survey were readily accessible to residents, family members, and legal representatives. During a Resident Council Meeting, residents reported they were unaware of where to find the survey results and did not know that such results were available for them to read. Interviews with staff, including the Infection Preventionist (IP) and the administrator (ADM), revealed that staff were also unclear about the location of the survey results. The ADM indicated that the survey results binder was supposed to be by the front door, but upon inspection, the area was empty, and the binder was not present. The ADM stated it had been updated recently but was not available at the time of observation. Further, the Director of Nursing (DON) acknowledged that if the survey result binder was not easily available, residents would not be able to know the results from the last survey or what the facility was working on to address identified problems. The DON was unsure how long the binder had been unavailable. A review of the facility's policy confirmed that residents have the right to examine survey results, as guaranteed by federal and state laws. This deficiency affected a census of 75 residents and was based on direct observation, interviews, and record review.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Failure to Maintain Functional Call Light System for Resident Assistance
Penalty
Summary
The facility failed to maintain a functioning resident call light system, resulting in staff not being directly alerted to residents' requests for assistance. Observations showed that when a resident pressed the call light in their room, the only indication was a light above the door, with no audible or visual alert at the nurses' station or a centralized staff area. Multiple staff members, including licensed nurses, confirmed that the call light system had not been working properly for at least a year, and that staff were expected to visually check for call lights while walking the halls. During several observations, staff walked past rooms with active call lights without responding, and there were periods when no staff were present in the hallways or at the nurses' station to notice the call lights. The administrator and DON acknowledged the lack of a functioning call light board or alarm and confirmed awareness of the issue for several months. Facility policy required that residents have a means of communication with nursing staff and that call lights be answered within 3-5 minutes. However, observations documented call lights remaining unanswered for extended periods, including one instance where a call light was left on for approximately 18 minutes before being answered. Staff interviews confirmed that the lack of an audible or visual alert at the nurses' station made it difficult to respond promptly to residents' needs, and that the system had not been repaired despite being reported as nonfunctional.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear medical justification or were given medications that limited their functional abilities, contrary to regulatory requirements.
Failure to Update Smoking Assessment and Post Oxygen Signage
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who was initially assessed as a nonsmoker upon admission, was observed smoking unsupervised in the designated smoking area with cigarettes and lighters in her possession. The resident's smoking risk assessment had not been updated to reflect her current smoking status, and staff responsible for supervision left the area, leaving her unattended. Facility policy required smoking assessments to be updated at admission, quarterly, annually, and as needed, but this was not followed. Additionally, another resident receiving oxygen therapy did not have an 'oxygen in use' sign posted at the entrance to their room, as required by facility policy. Observations confirmed the resident was on oxygen via nasal cannula, but signage was missing, which staff acknowledged was necessary to alert others to the presence of oxygen. The Infection Prevention nurse confirmed the lack of signage and stated that the expectation was for licensed nurses to ensure the sign was posted, but this was not done. The facility's policy on oxygen therapy specified that 'oxygen in use' signs should be placed both inside and outside the room.
Failure to Follow Medication Hold Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure safe monitoring and assessment of blood pressure and heart rate for a resident prescribed Midodrine, a medication used to treat low blood pressure. The physician's order specified that Midodrine should be held if the resident's systolic blood pressure exceeded 120 mmHg. Despite this, the medication was administered on seven occasions when the resident's systolic blood pressure was above the ordered threshold. This was confirmed through review of the resident's Medication Administration Record (MAR) and interviews with a licensed nurse and the Director of Nursing, both of whom acknowledged that the medication should not have been given under these circumstances. The resident involved had a medical history including hypertensive heart disease with heart failure and acute on chronic systolic congestive heart failure. The facility's policy required compliance with medication administration parameters and documentation of any medication errors, including notifying the physician and supervisor. However, there was no documentation in the resident's medical record of the seven medication errors, nor was the Director of Nursing made aware of these errors at the time they occurred.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals. No further details about specific residents, staff, or incidents are provided in the report.
Deficiency in Menu Planning and Nutritional Oversight
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met as outlined in their care plans. These deficiencies were observed through review of facility menus and dietary records, which showed lapses in menu preparation, adherence, and oversight by qualified dietary staff.
Failure to Document and Provide COVID-19 Vaccine Education
Penalty
Summary
The facility failed to provide and document education regarding the benefits and potential side effects of the COVID-19 vaccine for three of five sampled residents. Interviews with the Infection Preventionist (IP) revealed that while the COVID-19 vaccine was offered upon admission and staff were expected to educate residents about the vaccine, there was no documented evidence in the clinical records of the three residents that such education was provided. The IP confirmed during record review that education was not given to these residents prior to vaccine administration. Review of the facility's policies indicated that residents should be provided with education about the risks and benefits of the COVID-19 vaccine before it is offered, and that this education, along with consent and vaccine administration, should be documented in the medical record. However, the immunization records for the three residents only indicated the date the vaccine was given, with no documentation of education or consent. The IP acknowledged that the lack of education could result in residents not being aware of what symptoms or side effects to report to staff.
Failure to Maintain Resident Dignity and Privacy for Catheter Care
Penalty
Summary
A deficiency was identified when a resident with a urinary catheter was observed to have their catheter drainage bag exposed and not placed in a dignity bag, as required for privacy and dignity. During an observation, the catheter bag was seen hanging on the side of the bed without a privacy cover. The resident had been admitted with diagnoses including acute cystitis without hematuria and generalized muscle weakness. Review of the clinical record confirmed the presence of the catheter, and interviews with staff revealed that the use of dignity bags was expected as part of catheter care. Certified Nurse Assistant (CNA) staff acknowledged that dignity bags are typically used but sometimes become displaced or are removed. Licensed nursing staff confirmed that the catheter bag should have a privacy cover and that its absence could lead to embarrassment for the resident. The Director of Nursing (DON) stated that the dignity cover may have been forgotten due to the recent admission. Facility policy requires all residents to be treated with respect and dignity, including the right to privacy and confidentiality, which was not upheld in this instance.
Contradictory POLST and Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a resident's end-of-life wishes and emergent treatment preferences were accurately documented and consistent across medical records. Specifically, the resident's POLST (Physician Orders for Life Sustaining Treatment) form and the electronic medical record contained contradictory code status selections. The POLST form had both 'Do Not Attempt Resuscitation/DNR' and 'Full Treatment' options marked, which are mutually exclusive. The electronic physician's order also reflected this contradiction by listing the resident as DNR with full treatment. These inconsistencies were confirmed during interviews and record reviews with licensed nursing staff, who acknowledged that the documentation was confusing and could result in the resident not receiving care according to their wishes. The resident in question was admitted with multiple diagnoses, including cerebral infarction and vascular dementia. Interviews with the resident's representative clarified that the resident did not want CPR or any life-prolonging interventions if their heart or breathing stopped. The Director of Nursing confirmed that the POLST was completed incorrectly and was contradictory, acknowledging that such errors could lead to the resident receiving care that was not in line with their expressed preferences. Facility policy required review of POLST forms for validity upon completion, but this process failed to prevent the error.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
A resident with a history of chronic combined systolic and diastolic congestive heart failure was admitted to the facility and was observed receiving oxygen therapy at 2 liters per minute via nasal cannula. During interviews and record reviews, it was confirmed by both nursing staff and the Director of Nursing that the resident was on oxygen therapy as needed for shortness of breath. However, it was found that no care plan had been developed to address the resident's oxygen use, despite the resident's ongoing need for this intervention. The lack of a care plan for oxygen therapy was acknowledged by both the licensed nurse and the Director of Nursing, who confirmed that the facility's policy and procedure required a comprehensive, measurable, and time-framed care plan for each resident. The absence of this care plan meant that appropriate goals and interventions for the resident's oxygen therapy were not documented or communicated to staff, contrary to facility policy and professional standards of practice.
Failure to Complete Required AIMS Assessments for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to provide services that meet professional standards of practice for two residents who were prescribed antipsychotic medications. For both residents, the required Quarterly Abnormal Involuntary Movement Scale (AIMS) assessments, which are used to monitor for side effects of antipsychotic medications, were not completed. Specifically, one resident with diagnoses including severe unspecified dementia with psychotic disturbance, unspecified mood disorder, and unspecified psychosis had been taking Seroquel 50mg twice daily, but the AIMS assessment initiated was left completely blank, and no other AIMS assessments were found in the medical record. Another resident with diagnoses including vascular dementia, psychotic disorder with delusions due to a known physiological condition, mood disorder due to a known physiological condition with mixed features, major depression disorder unspecified, and anxiety disorder unspecified had been receiving Olanzapine 2.5mg daily, but their AIMS assessment was also left blank, with no other completed assessments found in the record. Interviews with licensed nursing staff and the Director of Nursing (DON) confirmed that both residents had been on antipsychotic medications for several months and that the AIMS assessments were incomplete or missing. The DON acknowledged that facility policy requires AIMS assessments to be performed quarterly for any resident on an antipsychotic and that these assessments had not been completed as required for the two residents. The failure to complete these assessments was confirmed through both record review and staff interviews.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to ensure adequate hydration for two residents, as required by facility policy and each resident's care plan. Observations and interviews revealed that both residents did not have fluids available at their bedside, despite having no fluid restrictions and being identified as at risk for dehydration. Staff, including licensed nurses and certified nurse assistants, confirmed the absence of fluids and acknowledged that fluids should have been available and within reach at all times. Both residents' care plans and hydration risk assessments specifically included interventions such as keeping fluids in reach, encouraging oral fluid intake, and monitoring for signs and symptoms of dehydration. As a result of these failures, one resident exhibited dry mucous membranes, chapped lips, and dry, peeling skin on the left leg, while the other resident had dry mucous membranes, chapped and cracked lips, and concentrated dark amber urine. Staff interviews confirmed these were signs and symptoms of dehydration and, in one case, increased risk for urinary tract infection due to the presence of an indwelling catheter. The Director of Nursing stated that it was the facility's expectation for residents to always have fluids available and within reach, and that the process required CNAs to provide fresh fluids at the beginning of each shift and with each meal.
Failure to Provide and Document Required Medications for Two Residents
Penalty
Summary
The facility failed to ensure the provision and documentation of routine and emergency medications for two residents, resulting in deficiencies related to pharmaceutical services. One resident, admitted with chronic obstructive pulmonary disease (COPD) and dyspnea, did not receive a physician-ordered as-needed (PRN) Ipratropium-Albuterol inhaler due to the medication being unavailable from the pharmacy. The resident reported not receiving the inhaler since admission, despite experiencing episodes of shortness of breath. Review of the Medication Administration Record (MAR) confirmed that the inhaler had never been administered, and nursing staff verified that the medication was not present in the medication cart. Interviews with nursing staff and the Director of Nursing (DON) revealed that the process for following up with the pharmacy and notifying the physician or responsible party about unavailable medications was not followed, and there was no documentation of alternative arrangements or communication regarding the missing medication. Another resident, admitted with sepsis, cellulitis, and a wrist fracture, was prescribed intravenous (IV) antibiotics following hospital discharge. Upon admission, the resident required immediate administration of IV Cefazoline, which was obtained from the Emergency Kit (E-kit) due to pharmacy delivery timing. However, the removal of the antibiotic from the E-kit was not documented in the medication log, pharmacy E-kit slips, or progress notes. Staff interviews confirmed that the required documentation process, which includes filling out pharmacy slips and logging the removal to notify the pharmacy for restocking, was not completed. The facility's policy and procedure required this documentation to ensure accurate record-keeping and timely replacement of emergency medications. Both deficiencies were confirmed through interviews with staff and review of facility policies, which outlined the required steps for medication ordering, receiving, and emergency kit management. The DON and Director of Staff Development acknowledged that the expected procedures were not followed in these cases, resulting in the unavailability of a prescribed inhaler for one resident and a lack of documentation for the use of an emergency antibiotic for another.
Failure to Accommodate Resident Dietary Preferences and Requirements
Penalty
Summary
During a lunch meal observation, two residents did not receive food and beverages in accordance with their documented dietary requirements and preferences. One resident, whose meal ticket specified 8 ounces of 2% milk as a beverage, did not receive the milk with their lunch. Another resident, who had a documented dislike of corn, was served coleslaw containing corn despite this preference being noted on their meal ticket. These discrepancies were identified through direct observation, review of meal tickets, and interviews with dietary staff. Interviews with the Dietary Supervisor and Registered Dietitian confirmed that kitchen staff are expected to follow meal tickets, and that residents' food preferences and dietary requirements should be honored. Facility policies reviewed indicated that food preferences are to be adhered to within reason, and substitutes should be provided for disliked foods. The failure to follow these procedures resulted in residents not receiving meals consistent with their documented needs and preferences during the observed meal service.
Failure to Provide Specialized Eating Utensils as Indicated on Meal Tickets
Penalty
Summary
The facility failed to provide specialized eating utensils to two residents during a lunch meal, despite documentation indicating the need for such devices. One resident, admitted with severe protein-calorie malnutrition and dysphagia, was observed receiving a regular plate and utensils, although their meal ticket specified a scoop plate and built-up utensils. The second resident, also with severe protein-calorie malnutrition and muscle weakness, received regular utensils instead of the required built-up utensils as indicated on their meal ticket. Observations confirmed that the kitchen staff did not follow the meal ticket instructions for these residents. Interviews with the Dietary Supervisor and a Licensed Nurse revealed that staff were expected to provide assistive devices as indicated on meal tickets, and that the omission was not in accordance with facility policy or physician orders. The Licensed Nurse confirmed that one resident had a physician order and care plan for special utensils, while the other did not. The Registered Dietitian also stated that kitchen staff should have followed the meal ticket instructions. Facility policy required that residents needing self-feeding devices receive them with each meal, as recorded on tray cards and diet profiles.
Failure to Provide Vaccine Education Prior to Pneumococcal Immunization
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of the pneumococcal vaccine to one resident prior to administration. Specifically, the clinical record for the resident did not contain documented evidence that education was provided before the resident received the PCV20 (Prevnar 20) vaccine. During interviews, the Infection Preventionist (IP) confirmed that education should be given to residents before vaccination, including information on the indication for the vaccine, possible side effects such as inflammation, pain, fever, and diarrhea, and that this education should be documented in the resident's progress notes. However, upon review, the IP acknowledged that there was no documentation or evidence that this education was provided to the resident in question. The lack of documented education meant the resident was not fully informed prior to receiving the vaccine, which is a violation of the resident's right to make an informed choice about their care. The facility's policy on resident rights, as well as federal and state laws, require that residents be informed and participate in their care planning and treatment. The IP also stated that not providing education could result in residents being unaware of what symptoms or side effects to report to staff.
Failure to Prevent Elopement and Ensure Safety for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with cognitive impairments and a history of wandering. Both residents had physician orders and care plans requiring the use of Wander Guard devices, with checks for placement and functionality to be performed and documented every shift. However, multiple instances were identified where these checks were not documented for both residents across several shifts, as confirmed by the Director of Nursing (DON) and review of the Medication Administration Records (MARs). The DON acknowledged that facility policy was not followed regarding these required checks. Additionally, the facility did not complete required elopement risk assessments for the two residents on a quarterly basis, as stipulated by facility policy and confirmed by the DON. One resident had not been reassessed for elopement risk since admission, and the other had not been reassessed since a previous quarterly assessment, despite both being identified as high risk for elopement. After one resident exited the facility unsupervised and was found in the street, there was no documentation of a change in condition, no care plan update, and no reassessment for elopement risk, contrary to facility policy. The incident involving the resident who exited the facility revealed further lapses in supervision and documentation. Staff interviews confirmed that the resident was found outside by a staff member, but it was unclear how long the resident had been outside or how the exit occurred. There was no documentation in the electronic medical record regarding the incident, and the required follow-up assessments and documentation were not completed. Furthermore, the Maintenance Supervisor reported that weekly checks of the Wander Guard system were performed but not documented, which was inconsistent with best practices and manufacturer recommendations.
Improper Transfer Technique Results in Resident Rib Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with osteoporosis and muscle weakness from a shower chair to her bed using a one-person 'bear-hug' technique, rather than the required two-person assist with a gait belt. The resident's care plan and Minimum Data Set (MDS) both indicated the need for substantial/maximal assistance and a two-person transfer due to her inability to bear weight and her high risk for fractures. However, the CNA performed the transfer alone and without a gait belt, contrary to facility policy and training. The incident resulted in the resident experiencing acute pain and a subsequent diagnosis of a right seventh rib fracture, as confirmed by emergency department evaluation. Interviews with staff revealed that the CNA was aware of the resident's fragile condition and had been trained not to use a hugging technique for transfers. The occupational therapist and director of staff development both confirmed that the proper method for transferring such residents involved two staff members and the use of a gait belt, and that hugging was never an appropriate or safe transfer method. Further review of the resident's records showed a lack of clear, accessible documentation in the electronic health record regarding the required transfer method, which contributed to the improper transfer. Staff interviews indicated confusion or lack of access to up-to-date transfer instructions, despite the resident's documented need for two-person assistance. The facility's policy explicitly required the use of a gait belt for dependent residents to prevent injuries, but this was not followed in the incident.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision to protect a resident from physical abuse by another resident. Resident 39, who has multiple sclerosis and limited mobility, was attacked in his room by Resident 79, who has a history of severe mental illness and violent behavior. Resident 79 entered Resident 39's room and struck him in the face multiple times, resulting in facial bruising, a cut lip, and head pain for Resident 39. Resident 79's clinical records revealed a pattern of violent behavior, including attacking staff members and exhibiting paranoid delusions. Despite these documented incidents, Resident 79 was not adequately supervised, leading to the assault on Resident 39. The facility's policy on abuse prevention and resident safety was not effectively implemented, as evidenced by the failure to prevent Resident 79 from accessing Resident 39's room and causing harm. Interviews with staff and other residents indicated a general sense of fear and lack of safety due to Resident 79's behavior. The facility's administrator acknowledged the attack but did not classify it as abuse, despite the facility's policy defining abuse as the willful infliction of injury. The incident highlights a significant deficiency in the facility's ability to protect residents from abuse and ensure their safety.
Inadequate Dietary Supervision and Oversight
Penalty
Summary
The facility failed to ensure that a Dietary Supervisor (DS) was onsite on a full-time basis, as required, to manage the day-to-day operations of the food and nutrition services. Although the DS was employed full-time, she was only present at the facility three days a week, working Monday, Tuesday, and Thursday. This arrangement was made after the DS retired and was called back by the administrator to help, with an agreement to work part-time. Consequently, the kitchen was left without proper supervision on Wednesdays, Fridays, and weekends, during which the Cooks were tasked with overseeing the kitchen staff, despite this not being part of their job description. The Registered Dietitian (RD), who worked only two days a week, also did not provide adequate oversight or consultation to the DS, as her time was primarily consumed by clinical duties. The lack of consistent oversight by qualified staff led to potential lapses in food and nutrition services, including meal distribution accuracy and safe food handling and sanitation. Interviews with kitchen staff revealed a lack of structure, organization, and consistency in the kitchen operations, with staff expressing the need for more guidance. The RD confirmed that she rarely checked the kitchen and had not conducted any monthly kitchen sanitation audits, leaving the responsibility to the DS, who was not present full-time. This deficiency affected the food services provided to 81 residents who relied on the kitchen for their meals.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed during a survey. Several tray line pans and serving utensils were found stacked and stored while still wet, which was confirmed by the Dietary Supervisor and Registered Dietitian as a practice that could promote bacterial growth. Additionally, a significant number of food items in the reach-in refrigerators were outdated or incorrectly labeled, including iced coffee, tuna, applesauce, and various salads, which were acknowledged by the Dietary Supervisor as expired and improperly managed. Further observations revealed stale and expired produce in the walk-in refrigerator, including cucumbers, lettuce, tomatoes, and green onions, which were confirmed by the Dietary Supervisor as spoiled and needing disposal. The ice machines at nursing stations one and two were not cleaned and sanitized according to the manufacturer's guidelines, with black and slimy substances found on the ice baffle. The Maintenance Supervisor and Maintenance Assistant acknowledged the oversight in the cleaning process, which did not include the necessary sanitizing step. Additional issues included unclean microwaves with chipping interior linings, improper thawing of meat by a cook, and a food processor with accumulated black substances. The facility also failed to monitor temperatures and label food items in residents' refrigerators, leading to expired and unlabeled food being stored. Staff members, including a cook and a dietary aide, demonstrated a lack of knowledge in food cooling processes and manual dishwashing procedures, respectively, indicating a need for further training and adherence to established guidelines.
Improper Garbage Disposal
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors by not properly securing one of the three garbage disposal bins located outside near the kitchen. During an observation, it was noted that the dumpster lid was not securely closed, leaving bags of trash exposed. This oversight was acknowledged by the Dietary Supervisor, who confirmed that the lid should always be tightly closed to prevent attracting pests and rodents. The Registered Dietitian also emphasized the importance of keeping garbage bins closed to avoid pest and rodent infestations. The facility's policy, as outlined in the departmental policy and procedure titled 'Miscellaneous Areas,' mandates that all food waste must be placed in sealed, leak-proof, non-absorbent, tightly closed containers to prevent nuisances or unsightliness. Additionally, the 2022 FDA Food Code specifies that outside receptacles for refuse containing food residue must have tight-fitting lids, doors, or covers. The failure to adhere to these guidelines posed a potential risk for pest infestation and disease spread within the facility.
Failure to Conduct Interdisciplinary Care Conferences
Penalty
Summary
The facility failed to honor residents' rights to participate in care conferences, which are essential meetings between healthcare professionals and residents or their families to discuss and plan individualized care. This deficiency was identified for five residents, who did not have their quarterly and comprehensive care conference meetings held as required. Interviews with residents revealed that they were either unfamiliar with care conferences or had not attended any since their admission to the facility. Record reviews confirmed that the interdisciplinary team (IDT) care conference records were incomplete, with only dietary and activities sections filled out, and lacked signatures from all required IDT members. The Social Services Director (SSD) admitted to not scheduling or coordinating IDT care conferences as required. Instead, the SSD met with residents individually and considered these meetings as care conferences, without involving the full IDT. The SSD acknowledged that all IDT members should meet together with residents and families to discuss all aspects of care, but this was not happening. The Registered Dietitian and MDS coordinator also confirmed that they did not attend IDT care conferences and that each department updated care plans independently, rather than as a coordinated team effort. Further interviews with the Director of Nursing (DON) and the facility Administrator confirmed that the facility's policy for IDT care conferences was not followed. The facility's policy required that care conferences be held within seven days of admission and then quarterly, with participation from all relevant disciplines. However, no such meetings were documented for the residents in question. The Administrator emphasized the importance of these meetings for coordinating care and ensuring all departments are aware of the residents' health and goals, but acknowledged that this process was not being implemented as intended.
Failure to Document and Match End-of-Life Wishes
Penalty
Summary
The facility failed to ensure that the end-of-life wishes and emergent treatment desires of six residents were accurately documented and available to staff. Specifically, Resident 70's POLST and documented code status did not match, leading to confusion among staff about whether to perform CPR. The POLST indicated a DNR status, while the physician's order stated a full code status. This discrepancy was acknowledged by a licensed nurse who found the information contradicting and confusing, highlighting the need for clarification to ensure the resident's wishes were honored. Additionally, the facility did not have copies of the Advance Directives for Residents 10, 21, 61, 70, 75, and 239 in their medical records. Interviews with the Business Office Manager and other staff confirmed that although these residents had executed Advance Directives, no attempts were made to obtain or document these directives in the residents' records. This lack of documentation meant that staff did not have access to critical information regarding the residents' end-of-life treatment preferences and designated decision-makers. The Administrator and Director of Nursing acknowledged the importance of having matching POLST and physician orders, as well as the presence of Advance Directives in medical records to ensure residents' wishes are respected. The facility's policy required that Advance Directives be obtained and placed in the medical record, but this was not followed, as evidenced by the absence of these documents in the residents' files. The failure to adhere to these policies resulted in the potential for residents' emergency treatment wishes not being honored.
Failure to Maintain Professional Standards in Glucometer Testing and Medication Administration
Penalty
Summary
The facility failed to maintain professional standards of quality in two key areas. Firstly, the glucometer quality control (QC) test logbook at Station 1 was not consistently completed for all active glucometer devices. During an interview and record review, it was revealed that some required nightly QC tests were not performed, and entries lacked QC lot numbers and expiration dates for the control solution. The Director of Nursing (DON) confirmed that the process for glucometer QC testing and recording was not followed as expected, which included recording device numbers, QC results, expiration dates, and the staff performing the tests. This was contrary to the facility's policy and procedure, which required nightly QC checks to ensure accurate blood glucose testing. Secondly, Resident 21's medication administration was mishandled. The resident, who was admitted with dementia and anxiety, was observed with a medication cup containing multiple pills left on their bedside table. The resident had requested the Licensed Nurse (LN) to leave the pills so they could take them one at a time. However, LN 2 acknowledged that this was a mistake, as they should have observed the resident taking the medication or removed the cup to prevent potential medication errors. The DON confirmed that the facility's policy, which required LNs to observe residents taking their medications and not leave medications unattended, was not followed. These deficiencies had the potential to result in inaccurate blood glucose tests and medication errors, which could affect the residents' health outcomes. The facility's policies and procedures were not adhered to, leading to these lapses in care quality and safety.
Deficiencies in Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to ensure safe pharmaceutical services for its residents, as evidenced by several deficiencies. Firstly, the disposition of non-controlled prescription medications was not documented. During an inspection of the medication room, discontinued and unusable prescription medications were found stored without any record of their destruction. The Charge Nurse was unaware of who was responsible for destroying these medications and could not locate any documentation. The Director of Nursing indicated that the night shift was supposed to handle the destruction and documentation, but this was not being done. Additionally, the emergency kits (E-kits) at Nurses Station 1 were not properly managed. The refrigerator E-kit was found unsealed and open, with no documentation of the medication removed. The oral medication E-kit had been opened and left unsealed for six days without being restocked. The Licensed Nurse present during the inspection was unsure of when the kits were opened and acknowledged issues with the re-seal tags. The facility's policy required documentation and immediate notification to the pharmacy when medications were removed from the E-kits, but this was not followed. Furthermore, the facility did not consistently sign or review prescription drug delivery manifests upon delivery. The Charge Nurse confirmed that the delivery slips were not consistently signed, which was necessary to verify the accuracy of the medications received. Additionally, there was a discrepancy in the documentation of narcotic medication for a resident. The Controlled Drug Record showed that oxycodone was signed out on several occasions, but there was no corresponding documentation in the Medication Administration Record. The Director of Nursing could not determine why the administration was not recorded, and the nurses involved were no longer employed at the facility.
Failure to Monitor Vital Signs for High-Risk Medications
Penalty
Summary
The facility failed to ensure proper monitoring and adherence to physician-ordered vital sign parameters for residents on high-risk medications. Resident 21 was administered three blood pressure medications on two occasions despite systolic blood pressure readings being below the physician-set parameters. This oversight occurred on specific dates when the systolic blood pressure was documented at 106 and 107, below the hold threshold of 110. Resident 77, who was on multiple medications for congestive heart failure, experienced a similar issue. On a particular date, despite a systolic blood pressure reading of 105, which was below the hold parameter, three medications were administered. This resulted in the resident experiencing very low blood pressure and dizziness, necessitating a transfer to the emergency room later that day. Resident 13, who was on medications for heart failure and irregular heart rhythm, also received medications despite vital signs being below the hold parameters. On two separate occasions, the resident's pulse was documented at 57 and 58, below the hold threshold of 60, yet the medications were administered. Interviews with staff revealed a lack of adherence to the facility's policy requiring vital sign checks and physician notification when parameters are not met.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure the safe use and monitoring of psychotropic medications for three residents, leading to deficiencies in care. Resident 21 was prescribed multiple mood-altering medications for anxiety, depression, and behavioral disturbances related to dementia. However, the facility did not document any non-pharmacological interventions for behavior modification, as required. Additionally, the behavior monitoring for Resident 21 was non-specific, and the behaviors did not pose a danger to self or others, indicating a lack of appropriate assessment and justification for the continued use of psychotropic medications. Resident 37 was also prescribed psychotropic medications for anxiety, depression, and schizoaffective disorder. Similar to Resident 21, there was no documentation of non-pharmacological interventions for behavior modification. Furthermore, Resident 37's use of a PRN anti-anxiety medication continued beyond 14 days without an assessment of its use and justification for its continuous need. The interdisciplinary team meetings did not address mental health issues and medication use or their effectiveness, highlighting a gap in coordinated care. Resident 58 was prescribed an antipsychotic medication on a PRN basis without a limit on its duration of use. The facility failed to document any interdisciplinary team meetings to address the use of psychotropic medications for Resident 58. The facility's policy required regular review of psychotropic medication use, but this was not consistently followed, as evidenced by the lack of documentation and assessment of the continued need for PRN medications. The facility's consultant pharmacist had previously educated the staff on regulatory requirements, but these were not adhered to, resulting in the deficiencies noted in the report.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to ensure safe storage and handling of medications and medical supplies, as observed in various areas including the medication cart, treatment cart, refrigerator, and medication room. At Station 1, the medication refrigerator storing insulin and vaccines had heavy frost, and the temperature was not documented twice daily as required. The facility's policy did not specify who was responsible for defrosting the refrigerator, and the CDC guidelines for vaccine storage were not followed, which could affect the potency of the medications. Additionally, expired glucometer control solutions and test strips were found in the medication room at Station 1, and the emergency kits were stored in a cabinet that could not be locked due to a malfunction. The facility's policy on emergency kits required them to be kept secure and checked periodically, but this was not adhered to. At Station 2, the treatment cart contained expired topical drugs and opened sterile products, which should not have been reused due to the risk of infection. Furthermore, hazardous medications were not stored safely to prevent touch contamination. At Station 1, a nurse handled hazardous drugs without gloves, and the medication cart at Station 2 stored hazardous drugs without proper containment. The facility's policy required hazardous drugs to be handled with personal protective equipment, but staff were not aware of these requirements. The Director of Nursing acknowledged the importance of handling hazardous drugs properly, but the facility's practices did not align with their policies or federal guidelines.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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