Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maclay Healthcare Center during CMS and state inspections, most recent first.
A cognitively impaired, high fall-risk resident with orthostatic hypotension and difficulty walking experienced a fall with fractures after the facility failed to monitor orthostatic BP as ordered and did not ensure safe ambulation practices. MD orders required monitoring for postural hypotension and documenting side effects of mirtazapine and antipsychotics on the MAR each shift, but records showed no orthostatic BP measurements, including no standing readings. Staff acknowledged they were not checking orthostatic BPs, and one LVN avoided standing measurements due to fear of a fall. The resident preferred open-back slip-on slippers, refused nonskid socks, and sometimes refused to use an assistive device, despite PT recommendations for supervised ambulation with a FWW and no training to ambulate more than a short distance without a device. The fall care plan did not address orthostatic BP monitoring, slipper use, or refusal of assistive devices. The resident ambulated about 71 ft in the hallway without an assistive device while wearing the slippers, appeared groggy, fell, and was found prone on the floor with severe left arm pain, later diagnosed with displaced fractures of the proximal humerus and great toe.
A resident with orthostatic hypotension, multiple fall-related diagnoses, and on antipsychotic medication was not monitored for orthostatic BP as ordered, with no standing BP readings documented over an extended period. A fall risk evaluation documented the resident as high risk but inaccurately recorded no recent falls, left the gait section incomplete, and understated the number of diagnoses contributing to falls, while also indicating no orthostatic BP drop without evidence that orthostatic BPs were taken. After a later fall and COC with severe left shoulder and arm pain, the resident remained on the floor until paramedics arrived, the COC form stated no orthostatic hypotension without documented orthostatic BP measurements, and required post-fall monitoring every shift for 72 hours was not documented on several shifts, contrary to facility policies and professional standards.
Surveyors found that staff failed to maintain accurate and timely medical record documentation for three residents. CNAs repeatedly recorded breakfast and lunch intake percentages at the same or nearly identical times in the afternoon, rather than documenting intake after each meal was consumed, for residents with dementia, muscle weakness, fractures, and other conditions on regular or CCHO diets. An LVN reported that a resident returned from a GACH in the morning, but the progress note entered by the ADON documented the return as occurring at night, creating a discrepancy in the recorded time of return. The DON acknowledged that documentation should reflect the accurate date and time and that the facility’s charting policy requires prompt, factual entries at the time care is provided or immediately afterward.
A resident with orthostatic hypotension, mobility impairment, and a history of falls was assessed as high fall risk, and physician orders required monitoring and documentation of postural hypotension and medication side effects on the MAR each shift. Despite this, staff did not document orthostatic BP monitoring, and Change in Condition evaluations after two falls either left the orthostatic assessment incomplete or indicated no orthostatic hypotension without recorded orthostatic BPs. The resident’s care plan, while identifying high fall risk and orthostatic hypotension, lacked specific interventions for orthostatic BP monitoring, the resident’s preference for open-toed, open-back rubber slippers, and the resident’s refusal to use an assistive device when ambulating, omissions confirmed by nursing staff and the DON as making the care plan incomplete.
A resident with acute kidney failure, pulmonary embolism, cognitive impairment, incontinence, and a fall history had physician orders for apixaban, daily constipation medications, and, after a fall, bilateral landing pads with bed and wheelchair alarms. The care plan included monitoring for anticoagulant side effects and constipation effectiveness, but staff documented apixaban administration without recording any side-effect monitoring, and did not notify the physician despite the resident’s repeated reports of prolonged constipation and requests for an enema. The resident’s fall care plan did not include the ordered bilateral landing pads, and both nursing staff and the DON acknowledged that this intervention was missing from the care plan, resulting in an incomplete, non-implemented person-centered care plan.
A resident with a stage 4 sacrococcyx pressure ulcer and bilateral unstageable heel ulcers did not receive wound care in accordance with provider orders and facility policy. On the scheduled reevaluation date for the sacrococcyx ulcer, no wound treatment was documented or provided, despite existing orders for daily Santyl and calcium alginate dressings. Later, after the wound provider changed heel ulcer orders from iodosorb to betadine, nursing staff continued to apply both betadine and iodosorb to the heels for several days without clarifying the conflicting orders, resulting in simultaneous use of two topical agents instead of following the updated single-agent regimen.
A resident with significant medical comorbidities and impaired cognition was on daily naloxegol and polyethylene glycol for constipation but experienced multiple days without a bowel movement and repeatedly complained of constipation and requested an enema. Nursing staff acknowledged that the resident complained "all the time" and reported a 13‑day period without a bowel movement, yet one LVN did not escalate the complaint to an RN or contact the physician, and an RN delayed and failed to properly document physician notification and did not initiate a change‑in‑condition (CIC) entry. Review of bowel records confirmed several days without documented bowel movements, and the DON stated that a CIC and prompt physician notification with PRN orders should have occurred under the facility’s change in condition policy.
A resident with essential HTN and intact decision-making capacity had a physician order for hydralazine 50 mg TID with instructions to hold the dose if SBP was below 110 mmHg. Review of the MAR showed that on one day in April, hydralazine was administered twice by two LVNs when the resident’s SBP readings were below the ordered hold parameter. In an interview, the DON confirmed that the hydralazine should have been held according to the physician order. Facility policy required that all medications be administered in accordance with prescribers’ orders.
A resident with acute kidney failure, pulmonary embolism with cor pulmonale, cognitive impairment, and a history of falls was prescribed apixaban 5 mg twice daily for PE/DVT. The care plan and the facility’s anticoagulation protocol required staff to monitor, document, and report signs of bleeding and other adverse reactions every shift. Review of the MAR showed the resident received apixaban over multiple days with no documented monitoring for bleeding or side effects. In an interview, the DON confirmed that apixaban carries bleeding and bruising risks, that the resident should have been monitored each shift, and that no such monitoring was documented.
The facility failed to follow its abuse investigation policy by not obtaining interviews or written statements from all staff assigned to residents involved in two separate resident-to-resident physical contact incidents. In one incident, a cognitively impaired resident with dementia and another resident with ESRD, COPD, and HTN had physical contact witnessed by an RN, but assigned LVNs and CNAs were not interviewed or documented as witnesses. In a second incident in the activity room, two cognitively intact residents using wheelchairs made contact, followed by physical contact between them; assessments showed no injuries, but assigned CNAs and an LVN were not interviewed, and no staff statements were documented for one of the residents. The facility’s abuse policy requires interviewing all relevant staff and obtaining signed, dated written witness statements, which the DON and administrator acknowledged was not done, resulting in incomplete investigations.
A resident with dementia and multiple chronic conditions was transferred to a hospital after an incident and remained there for several days, but two LVNs continued to document administration of ordered medications on the MAR during the period the resident was not in the facility. Progress notes clearly showed the dates of transfer and readmission, yet the MAR reflected doses of atorvastatin, levothyroxine, pantoprazole, and other medications as given in the interim. In interviews, the ADON and DON confirmed the resident’s absence during the documented administrations, acknowledged that the record was inaccurate, and noted that medications should have been documented as not given, contrary to the facility’s charting and documentation policy.
A resident with ESRD, COPD, and HTN, who was cognitively intact and had decision-making capacity, was ordered Lokelma for hyperkalemia but refused a scheduled dose. The MAR documented the refusal, yet no person-centered care plan was developed to address the medication refusal. During interviews, the ADON and DON acknowledged that the nurse should have notified the physician and that a care plan should have been created to address the refusal and ongoing management of hyperkalemia, contrary to the facility’s comprehensive care plan policy.
A resident with moderate cognitive impairment and multiple health conditions was pushed by a roommate with a history of behavioral issues, resulting in a fall. The incident was witnessed and reported by staff and another resident, and both parties involved admitted to their actions. The facility's abuse prevention policy was not followed, leading to a failure to protect the resident from physical abuse.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Staff did not immediately inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, resulting in a breakdown of required communication.
A resident with a history of dysphagia and neurological impairment did not receive a physician-ordered speech therapy and swallow evaluation because the facility lacked a speech-language pathologist. Despite ongoing documentation of swallowing difficulties and pocketing food, there was no evidence that the MD was notified about the inability to provide the ordered service or the resident's continued symptoms, leading to a decline in condition and transfer to acute care.
A resident with multiple medical conditions, including dysphagia and dementia, experienced weight loss and was not provided with a recommended nutritional supplement (magic cup) as advised by the RD. The DON confirmed the recommendation was not implemented, despite facility policy requiring intervention for undesirable weight changes.
A resident with a history of stroke, dysphagia, and dementia did not receive a physician-ordered speech therapy and swallow evaluation due to the absence of an ST in the facility. Despite ongoing documentation of swallowing difficulties and pocketing food, the evaluation was not completed, and there was no evidence that the MD was notified of the inability to provide the service. The resident's condition declined, resulting in transfer to an acute care hospital.
A resident with complex medical needs did not have accurate or complete documentation of a physician-ordered seven-day calorie count. The MAR lacked staff sign-off, and there were discrepancies between the Calorie Count and Meal Intake records, with conflicting or missing entries. The DON confirmed the records were inconsistent and not in accordance with facility policy.
Staff were observed wearing gloves in the hallway after providing care, including while transporting soiled linens and assisting residents, contrary to facility infection control policies. Interviews confirmed that gloves should be removed before exiting resident rooms and soiled linens should be bagged prior to transport, but these procedures were not followed, increasing the risk of infection transmission.
Two residents with significant medical and psychiatric histories were left unsupervised in a smoking patio, where a verbal altercation escalated to physical abuse involving a knife, resulting in one resident sustaining multiple injuries requiring hospital treatment. Staff and video evidence confirmed the absence of required supervision, and facility policy mandated staff presence during such activities.
Two residents with behavioral and cognitive impairments were left unsupervised in the smoking patio, leading to a verbal and physical altercation in which one resident used a knife to injure the other. Staff failed to follow care plans and facility policies requiring supervision during smoking, and the incident was not observed or interrupted by staff, resulting in injury and hospital transfer.
Sensitive medical documents and electronic records for several residents were left unattended and accessible to unauthorized individuals, including visitors and staff not involved in their care. A narcotic medication sheet was left visible at a nurse station, and clinical records were left open on a computer, violating facility policy and residents' rights to privacy and confidentiality.
The facility did not ensure that required physician or NP visits were conducted and documented in a timely manner for three residents with chronic medical conditions, as evidenced by missing or incomplete progress notes and gaps in medical records, contrary to facility policy and federal regulations.
Three residents experienced deficiencies in medical record documentation, including unsigned and undated physician telephone orders, lack of monthly physician review of order summaries, and the presence of blank forms signed by a nurse practitioner. These issues were confirmed through record reviews and staff interviews, revealing that required documentation and authentication were not completed as per facility policy.
Two residents with psychiatric and physical conditions engaged in a verbal and physical altercation in the smoking patio, resulting in one resident injuring the other with a knife. The facility did not thoroughly investigate the incident, failed to locate the weapon, and lacked staff supervision in the area at the time, as confirmed by video surveillance and administrator statements.
A resident with multiple mental health diagnoses, including anxiety disorder, schizophrenia, and psychosis, was admitted without an accurate PASARR Level I Screening reflecting their psychiatric conditions. Despite documentation of these diagnoses in admission records, MDS assessments, and psychiatric evaluations, the initial PASARR did not identify the need for a Level II Screening, resulting in a failure to coordinate assessments as required.
A facility failed to follow its medication storage policy by leaving a resident's discontinued medication in an unlocked drawer at the nurse station, rather than in a locked medication cart or room. The resident, who had intact cognitive skills and was admitted with conditions including diabetes and hypertension, did not have a physician order for the dietary supplement found. Both an LVN and the DON confirmed the oversight and the potential risk of unauthorized access.
A resident with COPD and other conditions did not receive the correct dosage of Atrovent as per physician orders due to a failure in verifying medication orders. The facility's policy requires clarification of unclear orders, which was not followed, leading to a potential medication error.
A facility failed to maintain a system for managing controlled substances, resulting in the unaccounted loss of a resident's Lorazepam medication. Despite having policies for handling and documenting controlled substances, the facility's procedures were not followed, as revealed by interviews with staff and an internal investigation. The resident, with a history of anxiety and other medical conditions, had a physician's order for the medication, but the exact number of missing tablets could not be determined.
A resident with intact cognitive skills and a preference to self-administer diabetes medication was not allowed to do so, as the facility failed to initiate the necessary assessment and care plan. Despite the resident's preference being communicated to nursing staff, the medication was administered by clinicians, contrary to the facility's policy that allows self-administration if deemed appropriate by the interdisciplinary team.
A facility failed to assess a resident's ability to self-administer Trulicity, a diabetes medication, as required by policy. Despite the resident's preference to self-administer, no assessment or physician's order was obtained, and the resident was allowed to self-administer the medication multiple times. The Director of Nursing confirmed the lack of assessment and documentation, which placed the resident at risk for medication errors.
A facility failed to create a care plan for a resident with type 2 diabetes, depression, and hypertension, who was receiving Trulicity. Despite intact cognitive skills, there was no order for self-administration, and no care plan was developed. Staff interviews revealed non-compliance with the facility's policy on self-administration, which required assessment, education, and a care plan. This oversight risked inconsistent care and potential medication complications.
A resident with type 2 diabetes, depression, and hypertension was found to be without a physician order to self-administer Trulicity, despite having intact cognitive skills. The facility's policy requires a physician order and an interdisciplinary team assessment for self-administration, which was not documented, potentially leading to confusion in care delivery.
A resident with type 2 diabetes was allowed to self-administer Trulicity without a physician's order, despite facility policy requiring such an order and an interdisciplinary team assessment. The resident self-administered the medication multiple times, as confirmed by a nurse and the DON, who acknowledged the failure to follow proper procedures.
A resident with moderate cognitive impairment was physically abused by another resident with severe cognitive impairment, resulting in a scratch on the arm. The incident was witnessed by another resident and confirmed as abuse by facility staff, highlighting a failure to protect residents from abuse as per facility policy.
A resident with severe cognitive impairment and multiple health issues was allegedly abused by a CNA, who reportedly hit the resident with a dirty brief. The incident was not reported to the necessary authorities within the required two-hour timeframe, as per facility policy. The delay in reporting was confirmed by interviews with facility staff, highlighting a deficiency in adhering to abuse reporting protocols.
A facility failed to maintain complete and accurate medical records for a resident with a hip fracture, dysphagia, and hypertension. Discrepancies were found between the resident's cognitive assessment and their documented decision-making capacity. An incident involving alleged rough handling by a CNA was not accurately recorded, violating the facility's policy for complete and accurate documentation.
A resident with severely impaired cognition was physically abused by another resident with a history of aggressive behavior in a shared room. The aggressor placed an arm around the victim's neck and punched the victim multiple times, resulting in swelling and bleeding. Staff confirmed the incident as physical abuse, and the facility's failure to prevent it was acknowledged.
A facility failed to provide a safe and homelike environment for four residents due to unresolved plumbing issues in their restrooms. Residents were forced to use alternative restrooms without proper communication or preparation, compromising their privacy and safety. The Director of Nursing was unaware of the situation, and the facility's policy on maintaining a homelike environment was not followed.
A resident with a known onion allergy was served baked beans containing onions, despite their allergy being documented in their medical records and meal tray ticket. The dietary staff failed to adhere to the facility's policies on food allergies, resulting in the resident being exposed to the allergen. The resident did not consume the beans, aware of their allergy, and expressed concern about the potential presence of onions.
A facility failed to treat residents with dignity and respect, as LVN did not knock before entering a resident's room and left medications for self-administration against policy. The resident felt disrespected, and other residents reported unprofessional behavior. Additionally, a CNA undressed a resident in view of the hallway, compromising privacy. These actions violated facility policies on resident rights and quality of life.
The facility failed to conduct restraint assessments and obtain necessary consents for three residents. A sensor pad alarm was used on a resident without assessment, and beds were placed against walls for two residents without physician orders or informed consent, restricting their movement.
A facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours, as required by policy. The resident, with chronic respiratory failure, depression, and atrial fibrillation, had orders for oxygen therapy, psychotropic medications, and an anticoagulant. However, no baseline care plans were created for these treatments, as confirmed by interviews with the RN and DON. This oversight had the potential to delay care and treatment, decreasing the resident's quality of life.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. A resident had medications at the bedside without approval, another used bed rails without a care plan, and two residents' ADL care plans were not followed. Additionally, care plans for medication use, including Mirtazapine and insulin, were not developed, risking delays in care.
The facility's nursing staff failed to rotate injection sites for insulin and enoxaparin for two residents, leading to potential adverse effects. Resident 70 and Resident 75 received repeated injections in the same areas, contrary to facility policy and professional standards. This oversight was confirmed by the nursing staff and the Director of Nursing, who acknowledged the risk of tissue damage.
The facility failed to ensure a safe environment and proper medication management for several residents. Fall mats were compromised by heavy furniture, increasing injury risk. Medications were left unattended at bedsides, despite residents not being approved for self-administration, posing risks of medication errors. Additionally, a wet floor was left unattended, creating a slip hazard. These actions violated facility policies and compromised resident safety.
A facility failed to document pre and post dialysis weights for a resident with ESRD, as required by their care plan. The resident had an order for weights to be taken on dialysis days, but the facility only recorded weights sporadically. Interviews with the MDSD and DON confirmed the lack of documentation in the MAR or weight summary, contrary to facility policy.
The facility failed to properly assess and manage bed rail use for several residents, leading to potential safety risks. Residents with cognitive impairments and high fall risks were observed with bed rails up despite evaluations indicating they were not needed. The facility did not conduct necessary assessments, obtain informed consent, or maintain proper documentation, as confirmed by the DON.
Failure to Monitor Orthostatic BP and Enforce Safe Ambulation Practices Resulting in Fall With Fractures
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall with injury for a cognitively impaired resident with a known history of falls and orthostatic hypotension. The resident was admitted with diagnoses including orthostatic hypotension, difficulty walking, muscle weakness, history of falling, and restless leg syndrome, and a subsequent History and Physical documented that the resident lacked capacity to understand and make decisions. A fall risk evaluation identified the resident as high risk for falls, and an MDS assessment showed moderately impaired cognitive skills for daily decision making, with a need for supervision for transfers and walking 150 feet and set-up assistance for walking 50 feet with two turns. The resident’s care plan for falls, initiated at admission, identified high fall risk factors such as impaired balance, poor safety awareness, orthostatic hypotension, history of repeated falls, and possible medication side effects. The facility did not implement and follow physician orders and internal policies related to orthostatic blood pressure monitoring and fall prevention. Physician orders dated 2/13/2026 directed staff to monitor for side effects of mirtazapine and antipsychotic medications, including postural/orthostatic hypotension and drowsiness, and to document observations with tally marks on the MAR every shift. Review of the MAR and vital signs logs showed no documented evidence that orthostatic blood pressures, including standing blood pressures, were obtained. An LVN acknowledged that orthostatic blood pressures were not being checked and that there were no standing blood pressure readings. Another LVN stated she did not obtain standing blood pressures due to fear the resident might fall if the blood pressure dropped. The DON confirmed that orthostatic blood pressure should have been obtained in lying, sitting, and standing positions per physician orders and that there was no documentation that this monitoring occurred. The facility also failed to ensure the resident used appropriate footwear and assistive devices while ambulating, and did not incorporate these issues into the care plan. Staff interviews revealed that the resident preferred to wear personal purple rubber slip-on slippers, refused nonskid socks, and occasionally refused to use an assistive device, instead sometimes pushing a wheelchair as a walker. Physical therapy records indicated the resident was not trained to ambulate more than ten feet without an assistive device and that discharge recommendations specified ambulation as desired using a front-wheeled walker with staff supervision; the rehabilitation director stated the therapy department did not recommend slippers and was not aware of the resident’s refusal to use assistive devices or preference for slippers. The fall care plan did not include interventions addressing orthostatic blood pressure monitoring, the use of personal slippers, or the resident’s refusal to use assistive devices. On the night of the incident, staff observed the resident walking in the hallway from the room toward the nurses’ station, approximately 71 feet, without an assistive device and wearing the purple slippers; the resident appeared groggy, then fell forward and was later found prone on the floor, complaining of severe left arm pain. The resident reported having walked in the room without a walker or wheelchair, then leaving the room without an assistive device while wearing the slip-on slippers, and next recalled being on the floor in front of the nurses’ station with severe left arm pain. The resident sustained a closed displaced fracture of the proximal left humerus and a closed displaced fracture of the proximal phalanx of the left great toe, requiring transfer to an acute care hospital.
Failure to Monitor Orthostatic BP, Assess Fall Risk, and Monitor After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice and physician orders for a resident with orthostatic hypotension and a history of falls. The resident was admitted with diagnoses including orthostatic hypotension, difficulty walking, muscle weakness, history of falling, and restless leg syndrome. A physician order dated 2/13/2026 directed staff to monitor for side effects of antipsychotic medications, including postural/orthostatic hypotension, and to document these side effects on the MAR every shift. Review of the MAR and vital sign logs from 2/10/2026 to 4/28/2026 showed no documented evidence that orthostatic blood pressures were obtained, specifically no standing blood pressure readings, despite the order and the resident’s risk factors. The facility also failed to appropriately assess the resident’s fall risk following a fall on 2/26/2026. The Fall Risk Evaluation dated 2/26/2026 showed a high fall risk score of ten and noted a history of multiple falls, but it inaccurately documented that the resident had no falls in the past 90 days. The Gait Evaluation section was not completed, and the form indicated there was no drop in orthostatic blood pressure between lying and standing, without any documented evidence that orthostatic blood pressures were actually taken. The Diagnosis Review section recorded only one to two diseases or diagnoses contributing to falls, although the resident had more than two such conditions. Following a subsequent fall and change of condition on 4/25/2026, the facility did not ensure consistent assessment and monitoring of the resident’s medical status. The Change in Condition Evaluation documented that the resident fell, complained of severe pain in the left shoulder and entire left arm, and did not tolerate range of motion of the left upper arm, and that the resident remained on the floor until paramedics arrived. The Functional Status Evaluation section stated the resident did not have orthostatic hypotension, but there was no documentation that orthostatic blood pressures were taken. Review of progress notes from 4/25/2026 to 4/28/2026 showed missing documentation of monitoring on multiple shifts, despite the expectation that the resident be monitored every shift for 72 hours after the change in condition. The DON and LVN acknowledged the lack of documentation of orthostatic blood pressures, fall risk elements, and post-fall monitoring, and the facility policies required timely, comprehensive assessments, orthostatic BP monitoring for at-risk residents, and ongoing monitoring after a change in condition.
Inaccurate Meal Intake and Return-from-Hospital Documentation in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for three sampled residents. For one resident with orthostatic hypotension, difficulty walking, muscle weakness, history of falls, and restless leg syndrome, the admission record showed admission in early February and a physician order for a consistent carbohydrate diet. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making. On a date in late April, an LVN stated that this resident returned from a general acute care hospital at 9:30 a.m., but the progress note entered by the Assistant Director of Nursing documented that the resident returned at 9:30 p.m. the same day, creating an inaccurate time of return in the medical record. The same resident’s nutritional task documentation for multiple days in April showed breakfast and lunch intake percentages recorded with identical or closely spaced afternoon times, such as both meals documented at 2:37 p.m., 2:06 p.m., 2:38 p.m., 2:41 p.m., 1:41 p.m., and similar patterns on other dates. CNA 3, who reviewed these records with the surveyor, stated that the documented times for the meal intake percentages were inaccurate and that meal intake should be documented after the meal had been consumed. This indicates that the timing of documentation for meal intake did not reflect when the meals were actually eaten. For a second resident with unspecified dementia, muscle weakness, and essential hypertension on a regular diet, the MDS showed intact cognitive skills for daily decision making. Review of this resident’s nutritional task records for April revealed that breakfast and lunch intake percentages were frequently documented at the same or nearly the same time, such as 12:30 p.m. and 12:31 p.m., or both meals at 1:43 p.m., 1:11 p.m., 1:41 p.m., 12:53 p.m., and other similar patterns. CNA 3 again stated that these documented times were inaccurate and that intake should be recorded after the meal was consumed. For a third resident with unspecified dementia, muscle weakness, and a displaced intertrochanteric fracture of the right femur on a regular diet, the MDS indicated severely impaired cognitive skills for daily decision making. This resident’s nutritional task records for April also showed breakfast and lunch intake percentages documented at the same or nearly the same time, including both meals at 12:53 p.m., 1:43 p.m., 1:42 p.m., 12:30 p.m., and 1:10 p.m. and 1:11 p.m. on another date. On one date, breakfast was documented at 2:32 p.m. and lunch at 12:33 p.m. CNA 3 stated that these times were inaccurate and reiterated that intake should be documented after the meal was consumed. In an interview, the DON stated that CNAs should document meal intake after residents consume their meals, that inaccurate documentation has the potential for inaccurate assessment that may lead to unidentified weight changes, and that documentation in the medical record should indicate the accurate date and time. The facility’s charting and documentation policy required prompt, accurate documentation at the time care is provided or immediately afterward, using clear, factual entries, which was not followed in these instances. These findings show that the facility did not ensure CNAs documented meal intake percentages at the correct time for three residents and did not ensure licensed nursing staff documented the accurate time of a resident’s return from the hospital, resulting in incomplete and inaccurate medical records.
Failure to Develop and Implement Comprehensive Fall-Prevention Care Plan
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with multiple fall risk factors and orthostatic hypotension. The resident was admitted with diagnoses including orthostatic hypotension, difficulty walking, muscle weakness, history of falling, and restless leg syndrome, and was assessed as high risk for falls on admission with a fall risk score of 15. Physician orders dated shortly after admission directed staff to monitor for side effects of mirtazapine and antipsychotic medications, including postural/orthostatic hypotension and drowsiness, and to document observations with tally marks on the MAR every shift. However, there was no documented evidence in the medical record that orthostatic blood pressure monitoring was performed or that these ordered side-effect observations were consistently documented. The resident experienced at least two documented falls during the review period. A Change in Condition (COC) Evaluation on one date showed the resident was found sitting on the floor beside the bed, but the Functional Status Evaluation section that would indicate whether orthostatic hypotension was present was not completed. A subsequent COC Evaluation documented another fall while the resident was ambulating in the hallway, with complaints of severe pain in the left shoulder and arm and inability to tolerate range of motion of the left upper arm. In that COC Evaluation, the Functional Status Evaluation section indicated the resident did not have orthostatic hypotension, but there was no documentation that orthostatic blood pressures were taken to support that conclusion. Review of the resident’s care plan and staff interviews showed that the care plan did not address several known risks and preferences related to falls. The fall care plan, initiated on admission, identified the resident as high risk for falls due to impaired balance, decreased or poor safety awareness, orthostatic hypotension, history of repeated falls, and possible medication side effects, but it lacked specific interventions for orthostatic blood pressure monitoring, the resident’s use of personal open-toed, open-back rubber slippers, and the resident’s refusal to use an assistive device while ambulating. A CNA and an LVN reported that the resident preferred thick purple rubber slippers and occasionally refused to use a wheelchair or assistive device when walking, and the LVN acknowledged there was no documentation of orthostatic monitoring and that the care plan was incomplete. The DON confirmed that the resident’s preferences and refusals, as well as orthostatic blood pressure monitoring, should have been reflected in the care plan and that these risks were not identified or addressed in the plan, contrary to the facility’s care planning and nursing assessment policies requiring individualized, person-centered care plans based on ongoing assessments.
Failure to Implement and Complete Person-Centered Care Plan for Anticoagulation, Constipation, and Fall Prevention
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, person-centered care plan for a resident with multiple complex medical conditions, including acute kidney failure, pulmonary embolism with acute cor pulmonale, and a history of falls. The resident was admitted with an order for apixaban, an anticoagulant, and the care plan dated 2/16/2026 included interventions to monitor for side effects and effectiveness of anticoagulant therapy, specifically listing signs such as blood in urine, black tarry stools, gastrointestinal symptoms, lethargy, bruising, and other adverse reactions. The Medication Administration Record for April 2026 showed that apixaban was administered twice daily from 4/1/2026 to 4/13/2026, but there was no documented monitoring of side effects on the MAR. During interview, the DON confirmed that residents on apixaban should be monitored for bleeding every shift with documentation on the MAR and acknowledged that the care plan intervention for anticoagulant monitoring was not followed. The deficiency also includes failure to implement the resident’s constipation care plan. The physician ordered naloxegol oxalate and polyethylene glycol daily for constipation, and the care plan for risk of constipation listed interventions of administering medications as ordered and monitoring for effectiveness with reporting of concerns to the physician. The MAR showed that both constipation medications were administered daily. However, the resident reported not having a bowel movement for 13 days and stated she had informed nurses without receiving new medication. Bowel elimination records from mid-March to mid-April documented multiple days without a bowel movement. Staff interviews revealed that the resident frequently complained of constipation, that staff were aware she was on routine constipation medications, and that there were no additional PRN constipation medications ordered. The resident reported requesting an enema about a week earlier that was not given, and staff confirmed there was no enema order and no documentation that the physician was notified about ongoing constipation, despite the care plan requirement to monitor effectiveness and report concerns. A further deficiency occurred in the failure to incorporate a physician-ordered fall prevention intervention into the resident’s care plan. After a documented change in condition on 2/26/2026, when the resident slid off the bed while attempting to go to the bathroom and was found sitting on the floor, the physician ordered bilateral landing pads and bed and wheelchair alarms. The change in condition evaluation recorded this order. However, review of the resident’s fall risk care plan dated 2/26/2026 showed that bilateral landing pads were not included as an intervention. During interviews, RN 2 and the DON acknowledged that the physician had ordered bilateral landing pads and that they were not reflected in the care plan, noting that care plans are intended to be a summary of care and should be complete with all interventions. The facility’s comprehensive care plan policy stated that all staff must follow the care plan and that it must include treatment orders and medication management, but in this case the ordered bilateral landing pads were not added to the care plan. Overall, the facility did not fully implement the resident’s existing care plans for anticoagulant monitoring and constipation, and did not develop a complete fall care plan that included the ordered bilateral landing pads. These actions and omissions resulted in a care plan that did not comprehensively guide staff in monitoring for anticoagulant side effects, responding to persistent constipation, or using all ordered fall-prevention measures, contrary to the facility’s own comprehensive care plan policy.
Failure to Provide and Follow Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards for one resident with multiple pressure injuries. The resident was admitted with diagnoses including osteomyelitis, generalized muscle weakness, and hypertension, and had intact cognitive skills and capacity to make decisions per the H&P and MDS. A physician order dated 2/6/2026 directed daily treatment to a stage 4 sacrococcyx pressure ulcer extending to the bilateral buttocks, with a plan to reevaluate on 3/9/2026. A wound assessment on 3/4/2026 documented the stage 4 ulcer with specific measurements and noted that the wound provider performed debridement and ordered Santyl with calcium alginate daily and as needed. However, review of the Treatment Administration Record for March showed no documented wound treatment to the sacrococcyx ulcer on 3/9/2026, and the DON confirmed there was no documented treatment provided that day. A second component of the deficiency concerns the facility’s failure to follow updated wound provider orders for the resident’s bilateral heel unstageable pressure ulcers. On 3/4/2026, physician orders directed cleansing both heels with normal saline, patting dry, applying iodosorb, and covering with a dry dressing daily for 30 days. A subsequent wound assessment on 3/25/2026 indicated the wound provider ordered betadine and dry dressing daily to both heels, and physician orders dated the same day specified cleansing with normal saline, patting dry, applying betadine, and covering with a dry dressing daily for 30 days to each heel. The care plan was also updated on 3/25/2026 to reflect betadine treatment to the left heel. Despite the new 3/25/2026 orders, the March TAR showed that from 3/26/2026 through 3/31/2026, nurses administered both betadine and iodosorb daily to the resident’s heels. During interview and record review, the DON stated that treatment nurses should have called the wound provider to clarify which order to continue when the new betadine order was added, given the prior iodosorb order, and noted concern about a possible drug interaction and the combination being too strong for the resident’s skin. Treatment Nurse 1 confirmed that both betadine and iodosorb were applied to the bilateral heels during that period and stated that the wound care order should have been clarified when the wound provider was at the facility on 3/25/2026. Facility policies on pressure ulcer management and wound documentation required individualized care plans, appropriate wound solutions and dressings per provider guidelines, and documentation at each treatment that matches the TAR, which were not followed in these instances.
Failure to Promptly Notify Physician of Resident’s Ongoing Constipation
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify the physician when a resident repeatedly reported constipation despite ongoing symptoms and documented bowel irregularities. The resident was admitted with significant medical diagnoses, including acute kidney failure, pulmonary embolism with acute cor pulmonale, and a history of falls. Physician orders at admission included daily naloxegol and polyethylene glycol for constipation. The resident’s H&P documented that she lacked capacity to understand and make decisions, and the MDS showed moderately impaired cognitive skills, a need for maximum assistance with ADLs, and that she was always incontinent of bowel function. The MAR for April showed that the ordered constipation medications were administered daily. During interviews, the resident reported she had not had a bowel movement for 13 days and stated she had informed nurses but no new medication was given. Review of the bowel elimination record from mid-March to mid-April showed multiple days with no bowel movement documented. One LVN stated the resident complained of constipation “all the time” and had most recently verbalized constipation the prior week; the LVN acknowledged she did not report this to the RN supervisor or notify the physician, and instead only told the resident she was already receiving naloxegol and polyethylene glycol. Another LVN reported that the resident said she had an order for an enema, but no such order was found in the medical record; this LVN reported the resident’s request for an enema and need for something to relieve constipation to the RN. The RN stated she was informed that the resident had not had a bowel movement for 13 days and that there was no PRN medication for constipation. The RN acknowledged that if there was no PRN medication, the physician should have been notified. She reported that she texted the physician during the night using the RN phone but had not documented this contact, and later review of the phone showed text messages sent only later that morning to two physician numbers, with no evidence of an earlier text at the time she initially claimed. The RN also stated there was no change-in-condition (CIC) documentation created for the resident’s constipation, and confirmed she did not create one. The DON stated that when the resident reported not having a bowel movement for 13 days, a CIC should have been created and the physician notified to obtain a PRN constipation medication, and that not notifying the physician delayed needed care. The facility’s change in condition policy required prompt recognition, assessment, provider notification, and documentation of changes in resident status, which was not followed in this case.
Failure to Follow Hydralazine Hold Parameters per Physician Order
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to the administration of hydralazine for a resident with essential hypertension. The resident was admitted with diagnoses including osteomyelitis, generalized muscle weakness, and essential HTN, and had a physician’s order dated 2/2/2026 for hydralazine 50 mg by mouth three times daily, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 mmHg. The resident’s History and Physical dated 2/4/2026 and MDS dated 2/9/2026 documented that the resident had the capacity to understand and make decisions and had intact cognitive skills for daily decisions. Review of the April 2026 MAR showed that on 4/10/2026, LVN 3 administered hydralazine at 1 p.m. when the resident’s blood pressure was 107/68 mmHg, and LVN 4 administered hydralazine again at 5 p.m. when the blood pressure was 105/67 mmHg, both below the ordered SBP hold parameter of 110 mmHg. During an interview and concurrent record review on 4/13/2026, the DON confirmed that the physician’s order required holding hydralazine when SBP was below 110 mmHg and acknowledged that the medication should have been held at both administration times on 4/10/2026. The facility’s undated Medication Administration Procedure, last reviewed on 4/24/2025, stated that all medications shall be administered in accordance with prescribers’ orders.
Failure to Monitor Anticoagulant Therapy for Signs of Bleeding
Penalty
Summary
The facility failed to ensure that a resident receiving apixaban, an anticoagulant, was monitored for side effects of bleeding as required by the resident’s care plan and facility policy. The resident was admitted with diagnoses including acute kidney failure, pulmonary embolism with acute cor pulmonale, and a history of falls, and had a physician’s order for apixaban 5 mg by mouth twice daily for pulmonary embolism/DVT. The resident’s history and physical documented that the resident did not have capacity to understand and make decisions, and the MDS showed moderately impaired cognitive skills and a need for maximum assistance with toileting, showering, dressing, and personal hygiene. The care plan for anticoagulant therapy directed staff to monitor for side effects and effectiveness and to monitor, document, and report adverse reactions such as blood-tinged urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle or joint pain, lethargy, and bruising. Review of the MAR for the month of April showed that the resident received apixaban twice daily from the 1st through the 13th, but there was no documented monitoring for bleeding or other side effects associated with apixaban. During an interview and concurrent record review, the DON acknowledged that apixaban is an anticoagulant with side effects of bleeding and bruising, and stated that the resident should have been monitored for bleeding every shift with documentation on the MAR. The DON confirmed that such monitoring was not documented. The facility’s anticoagulation clinical protocol required assessment for signs or symptoms of adverse drug reactions and monitoring for possible complications in individuals on anticoagulation, including nursing evaluation and communication with the physician if there was evidence of bleeding. Despite these requirements, there was no documentation that staff monitored or assessed this resident for bleeding while the resident was receiving apixaban.
Incomplete Abuse Investigations Due to Missing Staff Interviews and Statements
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse investigation policy by not fully interviewing or obtaining written statements from all staff assigned to residents involved in alleged resident-to-resident physical abuse incidents. For Resident 1, who was admitted with encephalopathy, unspecified dementia, and generalized muscle weakness and had moderately impaired cognitive skills, a Change of Condition Evaluation (CIC) dated 2/15/2026 documented that Resident 1 received physical contact from Resident 2. RN 1 witnessed and separated the residents and completed a head-to-toe assessment with no pain or injuries noted. The Director of Staff Development (DSD) stated that on that date RN 1, LVN 2, and CNA 2 were assigned to Resident 1. The Director of Nursing (DON) reviewed the facility’s staff interview document dated 2/15/2026 and confirmed that it contained statements from RN 1, two clinical students, and one clinical instructor, but there were no statements from LVN 2 or CNA 2, despite their assignment to Resident 1. For Resident 2, who was admitted with ESRD, COPD, and hypertension, the MDS and History and Physical indicated intact cognitive skills and capacity to understand and make decisions. A CIC dated 2/15/2026 documented that RN 1 witnessed Resident 2 make physical contact with Resident 1, separated them, and assessed Resident 2 with no pain or injury. The facility’s Five-Day Investigation Summary indicated that staff witness statements were reviewed. The DSD stated that on 2/15/2026, RN 1, LVN 1, and CNA 5 were assigned to Resident 2. However, upon review of the staff interview document dated 2/15/2026, the DON confirmed that only statements from RN 1, two clinical students, and one clinical instructor were present, and there were no statements from LVN 1 or CNA 5, even though they were assigned to Resident 2. For Resident 3, admitted with acute kidney failure, difficulty in walking, and generalized weakness, the MDS and H&P indicated intact cognitive skills and decision-making capacity. A CIC dated 2/16/2026 documented that Resident 3 maneuvered an electric motorized wheelchair in the activity room, and the wheelchair made contact with Resident 4’s wheelchair, after which Resident 4 turned, extended an arm toward Resident 3, and made physical contact. Staff intervened, separated the residents, and assessed them with no visible injury and no pain reported. CNA 4 stated she was assigned to Resident 3 and was with another resident when the incident occurred. LVN 3 stated she was informed that her resident (Resident 3) hit Resident 4 in the right shoulder. The DSD stated that RN 1, LVN 3, and CNA 4 were assigned to Resident 3 on 2/16/2026. The DON reviewed the staff interview document and confirmed it contained a statement from LVN 3 but no statement from CNA 4, despite her assignment to Resident 3. For Resident 4, admitted with acute embolism and thrombosis of a deep vein of the left lower extremity and hypertension, the H&P indicated capacity to understand and make decisions. A CIC dated 2/16/2026 documented that Resident 4 extended an arm toward Resident 3 and made physical contact, and that Resident 3 hit Resident 4’s left knee on the table. RN 1 offered pain medication, which Resident 4 refused, and assessed Resident 4 with no visible injuries. LVN 4 stated he was assigned to Resident 4 but was not in the activity room when the incident occurred and that RN 1 informed him of the incident; he stated he checked Resident 4 and found no pain or injury. The Activity Director reported that Activity Staff 1 observed Resident 4’s wheelchair bump into Resident 3’s wheelchair in the activity room. The DSD stated that RN 1, LVN 4, and CNA 3 were assigned to Resident 4 on 2/16/2026. The DON reviewed the staff interview document and confirmed that no staff statements were documented for this incident and specifically that there were no statements from LVN 4 or CNA 3. Review of the facility’s policy and procedure titled “Abuse Investigation and Reporting,” last reviewed 4/2025, showed that the individual conducting the investigation must, at a minimum, interview staff members on all shifts who had contact with the residents during the period of the alleged incident, interview roommates, family members, and visitors, review all events leading up to the alleged incident, and document the investigation completely and thoroughly. The policy further states that witness statements are to be obtained in writing, signed, and dated, either written by the witness or obtained by the investigator. The DON stated that, based on this policy, the investigations were not complete. The Administrator stated that for the allegations on 2/15/2026 and 2/16/2026, she interviewed RN 1 and Activity Staff 1 but did not interview the assigned staff for the involved residents, and acknowledged that the investigations for Residents 1, 2, 3, and 4 were incomplete.
Inaccurate MAR Documentation for Hospitalized Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one sampled resident by inaccurately documenting medication administration while the resident was hospitalized. The resident had been admitted with diagnoses including other encephalopathy, unspecified dementia, and generalized muscle weakness, and had multiple active physician orders for medications such as atorvastatin, levothyroxine, docusate, ferrous sulfate, lubiprostone, pantoprazole, quetiapine, and senna. The resident’s Minimum Data Set indicated moderately impaired cognitive skills for daily decisions. Record review showed that the resident was transferred to a general acute care hospital on 2/15/2026 at 7:20 p.m. following an incident in which another resident made physical contact; a head-to-toe assessment revealed no pain or injuries, and the physician ordered transfer for further evaluation. Progress notes documented the transfer on 2/15/2026 and the readmission from the hospital on 2/19/2026 at 3:02 p.m., confirming that the resident was not present in the facility between those dates and times. Despite the resident’s absence, the February 2026 Medication Administration Record showed that LVN 6 documented administration of atorvastatin, quetiapine, senna, docusate, ferrous sulfate, pantoprazole, and lubiprostone on specific dates and times while the resident was at the hospital, and LVN 7 documented administration of levothyroxine and pantoprazole during the same period. In interviews, the ADON confirmed that the resident was at the hospital during these documented administrations and stated that LVN 6 and LVN 7 should have verified the resident’s presence and identity before documenting medication administration, acknowledging that the medical record was inaccurate. The DON also stated that the nurses should not have documented medication administration when the resident was at the hospital and that medications should have been documented as not given, noting that the inaccurate medical record could cause confusion in care. The facility’s charting and documentation policy required that all medications and care be documented promptly and accurately according to facility and regulatory requirements. These failures had the potential to result in medication errors, cause confusion in care and the medical records containing inaccurate documentation.
Failure to Care Plan for Resident’s Refusal of Hyperkalemia Medication
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of a person-centered comprehensive care plan related to a resident’s refusal of ordered medication. The resident was admitted with diagnoses including end stage renal disease, COPD, and essential hypertension. An MDS assessment documented that the resident’s cognitive skills for daily decision-making were intact, and a subsequent H&P stated the resident had the capacity to understand and make decisions. A physician’s order directed administration of Lokelma 10 grams orally on specific days for treatment of hyperkalemia. The MAR for the relevant month showed that on 2/1/2026 the resident refused the ordered Lokelma dose. During concurrent record review and interview, the ADON confirmed there was no care plan addressing the resident’s refusal of Lokelma and acknowledged that the nurse should have notified the physician and documented the refusal. The ADON stated that without a care plan for the refusal, there would be no intervention to correct the resident’s hyperkalemia and this could potentially cause further increase in potassium levels. In a separate interview, the DON stated that a care plan should have been developed for the resident’s medication refusal to create a new treatment plan to prevent further elevation of potassium, and that without such a care plan the resident’s hyperkalemia might not be corrected. The facility’s comprehensive care plan policy indicated that a CCP is to be developed for each resident to ensure individualized, resident-centered care addressing medical needs and updated based on resident conditions and preferences, which was not followed in this case.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. On the day of the incident, two residents sharing a room were involved in a physical altercation. One resident, who had a history of behavioral and emotional challenges, became upset after his roommate had a bowel movement on his own bed and threatened to do the same on the other resident's bed. The upset resident then pushed his roommate in the back with three fingers, causing the roommate to fall to the floor in a semi-sitting position, leaning on his right side. The resident who was pushed had multiple diagnoses, including schizoaffective disorder, major depressive disorder, and osteoarthritis, and required moderate assistance with several activities of daily living. The resident's cognitive functioning was moderately impaired. The resident who did the pushing had intact cognitive functioning but a documented history of verbal disagreements with his roommate. Multiple staff members, including an LVN and an RN, confirmed that the incident was an act of physical abuse and recognized the potential for injury. The incident was witnessed and reported by another resident and staff, and both residents involved admitted to their actions during interviews. The facility's abuse prevention policy, which maintains zero tolerance for abuse, was not upheld in this instance, as the resident was subjected to physical abuse by another resident while under the care of the facility.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred.
Failure to Notify Physician of Inability to Provide Ordered Speech Therapy and Resident's Ongoing Swallowing Difficulties
Penalty
Summary
The facility failed to notify the attending physician when a resident did not receive a physician-ordered speech therapy (ST) and swallow evaluation due to the absence of a speech-language pathologist (SLP) in the building. The resident, who had a history of hemiplegia, hemiparesis, dysphagia, dementia, and depression, was admitted with significant swallowing difficulties, including pocketing food and choking. Despite a physician's order for an ST and swallow evaluation, the service was not provided because the facility had no ST available after the therapist resigned. The Director of Rehab confirmed that the last day an ST was present was prior to the order, and the resident was discharged from ST services due to this lack of availability. Progress notes and care plans indicated ongoing monitoring of the resident's swallowing difficulties, with repeated documentation of continued pocketing and difficulty swallowing over several days. However, there was no documentation that the physician was notified about the facility's inability to provide the ordered ST evaluation or about the resident's persistent symptoms. The Director of Nursing acknowledged during interviews that there was no evidence of physician notification regarding the lack of ST services or the resident's ongoing swallowing issues. The resident's condition continued to decline, culminating in an acute change in condition where the resident was unable to eat, was coughing, and continued to pocket food, ultimately requiring transfer to a general acute care hospital. Facility policy required notification of the physician and family when changes in condition or inability to provide ordered services occurred, but this was not done in this case, resulting in a delay of care for the resident.
Failure to Implement Dietitian's Recommendations for Nutritional Supplementation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following the Registered Dietitian's (RD) recommendations. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, dysphagia, dementia, and depression, experienced weight loss over a period of time. The care plan included monitoring for signs of dysphagia and providing supplements as ordered. The physician's orders specified a regular diet with pureed texture, nectar thickened liquids, and large portion protein per meal. The RD recommended providing a magic cup supplement daily at lunch due to the resident's weight loss and variable oral intake. Despite these recommendations, the facility did not provide the recommended magic cup supplement to the resident. The Director of Nursing (DON) confirmed that the RD's recommendation was not implemented and acknowledged that this could lead to further weight loss. The facility's policy required evaluation and intervention for undesirable weight changes, including ensuring adequate calorie and protein intake, but this was not followed in this case.
Failure to Provide Ordered Speech Therapy and Swallow Evaluation
Penalty
Summary
The facility failed to provide a required Speech Therapy (ST) and swallow evaluation for a resident with a history of hemiplegia, hemiparesis following cerebral infarction, dysphagia, dementia, and depression. The resident was admitted and readmitted with these diagnoses, and care plans were in place to monitor for signs and symptoms of dysphagia, including pocketing, choking, and difficulty swallowing. On a specific date, the resident was observed to be pocketing food, and the family reported swallowing difficulties. The physician was notified and ordered a speech and swallow evaluation, as well as a calorie count. Despite the physician's order for an ST and swallow evaluation, the service was not provided because the facility did not have an ST available at the time. The Director of Rehab confirmed that the last day an ST was present was prior to the order, and the resident was discharged from ST services due to the lack of available staff. There was no documentation that the physician was notified about the inability to provide the ordered evaluation. Progress notes continued to document the resident's ongoing difficulty with swallowing and pocketing food in the days following the order. The resident's condition declined, with continued reports of difficulty swallowing, pocketing food, and eventually being unable to eat, coughing, and requiring transfer to a general acute care hospital. Staff interviews confirmed that the resident choked during feeding attempts and that the lack of ST services was known to both the Director of Rehab and the DON, but no alternative arrangements or notifications to the physician were documented. Facility policy required provision of rehabilitative services as indicated and notification of the physician and family when significant changes in condition or treatment occurred, but these were not followed in this case.
Failure to Accurately Document Calorie Counts and Maintain Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident with multiple diagnoses, including hemiplegia, hemiparesis, dysphagia, dementia, and depression. Specifically, the facility did not accurately document the required seven-day calorie count on the resident's Medication Administration Record (MAR), as there was no indication that staff had signed off on this task. Additionally, discrepancies were found between the resident's Calorie Count records and Meal Intake documentation for several days, with conflicting percentages and missing entries. The Director of Nursing (DON) confirmed that the documentation was inconsistent and that the MAR should have been checked off and initialed by licensed staff to validate that the task was completed. The facility's policy and procedure on charting and documentation requires that treatments or services performed be objectively, completely, and accurately documented in the resident's medical record. However, the review revealed that the calorie count documentation did not align with the meal intake records, and the MAR was not properly completed to reflect the physician's order. The DON acknowledged these inconsistencies and the inability to validate that the required interventions were performed, resulting in inaccurate documentation of the resident's records.
Failure to Follow Infection Control Protocols for Glove Use and Linen Handling
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols by wearing gloves in the hallway after providing care to residents. Certified Nursing Assistants (CNAs) were observed exiting resident rooms while still wearing gloves and handling items such as dirty linens and transporting residents in a shower chair. These actions were directly observed by surveyors and confirmed through interviews with the involved staff, who acknowledged that gloves should not be worn in the hallway to prevent the spread of infection. One resident with hemiplegia and hemiparesis required substantial assistance with activities of daily living (ADLs), and a CNA was seen leaving the resident's room wearing gloves while carrying a plastic bag of dirty linens to the dirty linen room. Another resident with acute respiratory failure and hypoxia, who required moderate assistance with ADLs, was transported in a shower chair by a CNA wearing gloves in the hallway. A third resident, dependent on staff for ADLs and diagnosed with type 2 diabetes mellitus, had their soiled linens carried by a CNA without a plastic bag, with the CNA wearing gloves in the hallway and entering the dirty linen room. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that staff are expected to remove gloves before exiting resident rooms and perform hand hygiene to prevent infection transmission. Review of facility policies also indicated that gloves are to be discarded in the room where care is provided and that soiled linens should be placed in a plastic bag before transport. These observations and staff admissions demonstrated a failure to follow established infection control procedures, creating the potential for the spread of communicable diseases within the facility.
Plan Of Correction
F 880 F 880 F 880 Maclay Healthcare Center makes every effort to comply with the State and Federal regulations. Nothing in this plan of correction is an admission otherwise. Maclay Healthcare Center submitted this plan of correction to comply with the State and Federal regulations and does not waive any objection obtained. This plan of correction is our credible allegation of compliance for deficiency noted findings of the California Department of Public Health during the entity reported incident no. CAo0958842 which was conducted on 4/28/25. F880 Infection Prevention and Control =E Immediate Corrective Action: • On 4/28/25, Infection Prevention Nurse provided a one-on-one in-service and review with CNA 2, on the infection control and prevention policy, focusing on the importance of not wearing gloves in the hallway to prevent the spread of infection. • On 4/28/2025, Infection Prevention Nurse provided a one-on-one in-service and review with CNA 3 on the infection control and prevention policy, focusing on the importance of not wearing gloves while transporting residents in a shower chair to prevent the spread of infection. • On 4/28/2025, Infection Prevention Nurse provided a one-on-one in-service and review with CNA 4 on the infection control and prevention policy, focusing on the importance of placing soiled linens in a plastic bag prior to transporting them to the soiled linen barrel and not wearing gloves in the hallway to prevent the spread of infection. • On 4/28/25, 4/29/25, DON and IP Nurse provided an in-service to licensed nurses and CNAs regarding the use of PPE-gloves, hand hygiene/handwashing and facility policy on transporting soiled linen to the dirty linen room or soiled linen barrel to prevent the spread of infection. Other residents affected by this deficient practice: • On 4/28/2025 and 4/29/2025, the Infection Prevention Nurse and the assistant DSD staff conducted rounds during resident care and observed staff during and after care of residents to ensure that staff were removing gloves prior to exiting the resident room were performing hand hygiene/handwashing and that CNA staff are placing soiled linen in a plastic bag when transporting soiled linens in
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when two residents, both present in the facility's smoking patio, engaged in a verbal altercation that escalated into a physical confrontation. During this unsupervised period, one resident used a knife to inflict injuries on the other, resulting in abrasions to both knees and a laceration on the left thumb that required eight stitches. The incident occurred while both residents were in their wheelchairs in the designated smoking area, and no staff were present to supervise or intervene. The resident who was injured had a medical history including dementia, schizophrenia, and depression, with documented moderate cognitive impairment and partial dependence on staff for activities of daily living. The other resident involved had diagnoses of anxiety disorder, schizophrenia, and hemiplegia/hemiparesis following a cerebral infarction, with intact cognition. The inventory of personal effects for the resident who used the knife did not indicate possession of such an item, and the facility's policies required supervision for residents with smoking privileges and prohibited weapons on the premises. Staff interviews and video surveillance confirmed that the residents were left unsupervised in the smoking patio, contrary to facility policy. The altercation was not witnessed by staff, and the physical abuse was only discovered when the injured resident approached the nursing station for assistance. Staff acknowledged that supervision was required and that the incident could have been prevented if staff had been present to monitor and separate the residents at the onset of the verbal altercation.
Removal Plan
- Resident 1 approached Nursing Station 500 for assistance. RN 1 gave first aid and called LVN 1 to attend to Resident 1. RN 1 asked Resident 1 how he got the cut and Resident 1 stated he tried to seize the knife from Resident 2. RN 1 immediately went to the smoking patio to check and found Resident 2 about to go inside the facility with no visual of the knife.
- RN 1 initiated a change of condition on Resident 2, did a body check, noted an abrasion on Resident 2's left hand and wrist, gave first aid, and called Resident 2's primary MD who ordered transfer to GACH 2 for further evaluation. Resident 2 was assigned a 1:1 sitter to monitor aggressive behavior and was transferred for psychiatric evaluation and treatment.
- RN 1 initiated body assessment on Resident 1 and noted abrasions on both knees. RN 1 initiated the change of condition on Resident 1, called paramedics who arrived and transferred Resident 1 to GACH 1. RN 1 called the local police.
- Resident 1 came back from GACH 1 with eight stitches on left thumb. Resident 1 was monitored for 72 hours for fall complications and symptoms of emotional distress. Social Services staff continued wellness visits for emotional support and safety. Psychiatrist visited Resident 1 and Psychologist visited Resident 1.
- DON provided 1:1 education to RN 1 regarding facility policies for abuse prevention. DON provided 1:1 education to RN 2, CNA 1, and CNA 2 regarding resident safety, supervision, and abuse prevention and management. LVN 1 will be educated prior to returning from vacation.
- Facility readmitted Resident 2 from GACH 2 and provided 1:1 sitter to monitor aggressive behavior. Social Services staff continued wellness visits to Resident 2. Psychiatrist saw Resident 2. Local police apprehended Resident 2.
- Administrator posted 'No Weapons Allowed' signs in the facility at the front entrance, facility entrance, and employee lounge, with additional postings planned.
- DSD, Administrator, DON, and Assistant Administrator provided all facility staff with in-service training for all types of abuse.
- The facility made efforts to locate the knife used by Resident 2: attempted to search Resident 2 (refused), searched the smoking patio, asked police to conduct body search (declined), searched Resident 2's room and belongings, searched trash carts and laundry area, conducted searches in all residents' rooms and belongings, searched the rooftop, reviewed video footage, and will continue exhaustive search until the knife is found. Once found, the knife will be photographed, bagged, handled with caution, and turned in to police. Notification will be sent to SSA.
- DSD, Administrator, DON, and Assistant Administrator conducted in-services to staff regarding resident-to-resident verbal altercation, separating residents to avoid escalation, recognizing potential threats, and handling situations where a weapon may be involved.
- A new policy and procedure for Firearms and Other Weapons was initiated and will be presented to the Medical Director during an emergency meeting.
- RN Mentor in-serviced the Administrator and DON on the policy and procedure for abuse, how to detect and what is the definition of abuse.
- Department head managers during routine rounds will conduct safety room checks on assigned rooms to inspect for sharp objects. Any sharp objects found will be seized and reported to the Administrator for follow-up.
- Upon admission and during quarterly IDT meetings, Social Services will educate residents and representatives about the abuse policy and the protocol of not bringing sharp objects or weapons to the facility. Any such findings will be confiscated and handed to the Administrator/DON.
- Upon returning from out on pass, if residents or representatives bring any items back to the facility, the charge nurse or RN supervisor will ask for any items to be added to the inventory list.
Failure to Supervise Residents in Smoking Patio Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision to two residents in the smoking patio, resulting in a physical altercation. On the morning of the incident, both residents, who had documented histories of behavioral issues and required supervision while smoking, were left unsupervised in the designated smoking area. One resident, with diagnoses including dementia, schizophrenia, and a history of disruptive behavior, and another resident, with anxiety disorder, schizophrenia, and hemiplegia, engaged in a verbal argument that escalated to physical violence. The altercation culminated in one resident using a knife to injure the other, causing a laceration to the left thumb and abrasions to both knees. The injured resident required hospital transfer and received eight stitches for the thumb wound. The investigation revealed that staff failed to follow the facility's own policies and care plans, which required direct supervision for both residents during smoking times due to their non-compliance and risk behaviors. The smoking patio was accessed outside of scheduled smoking times, and the staff member responsible for opening the door left it unattended, allowing the residents to enter without supervision. Video surveillance confirmed that no staff were present in the smoking patio during the incident, and the area was not fully visible from the hallway, further limiting oversight. Interviews with staff and review of care plans confirmed that both residents should have been supervised while in the smoking patio, and that this supervision was not provided at the time of the incident. Additionally, the facility's inventory records did not indicate that the resident who used the knife was in possession of such an item, and subsequent searches failed to locate the weapon. The lack of supervision and failure to enforce safety protocols directly led to the altercation and injury. The facility's policies on resident safety, supervision, and smoking practices were not adhered to, resulting in a situation where residents were exposed to significant harm.
Removal Plan
- Resident 1 approached Nursing Station 500 for assistance; RN 1 provided first aid and called LVN 1 to attend to Resident 1, then checked the smoking patio for Resident 2 and the alleged knife.
- RN 1 initiated a change of condition on Resident 2, performed a body check, provided first aid, called Resident 2's primary MD, and transferred Resident 2 to GACH 2 for further evaluation; Resident 2 was assigned a 1:1 sitter.
- RN 1 initiated a body assessment on Resident 1, noted abrasions, initiated a change of condition, called paramedics, and Resident 1 was transferred to GACH 1; local police were called.
- Resident 1 returned from GACH 1 with eight stitches; Resident 1 was monitored for 72 hours for complications and emotional distress; Social Services and mental health professionals provided support.
- The DON provided 1:1 education to RN 1 regarding abuse prevention, resident supervision, and following the smoking schedule; DON provided 1:1 education to RN 2, CNA 1, and CNA 2; LVN 1 to be educated before returning from vacation.
- Resident 2 was readmitted from GACH 2 and provided a 1:1 sitter; Social Services and mental health professionals continued wellness visits; police apprehended Resident 2.
- The Administrator posted 'No Weapons Allowed' signs at facility entrances and employee lounge, with additional postings planned.
- The DSD, Administrator, DON, and Assistant Administrator provided in-service training for all staff on all types of abuse.
- The facility made multiple efforts to locate the knife, including searching Resident 2 (who refused), searching the smoking patio, requesting police assistance, searching Resident 2's room and common areas, and reviewing video footage; ongoing efforts to locate the knife will continue, and the Administrator will notify authorities if found.
- Department Heads conducted resident safety checks using the inventory of personal belongings log to identify weapons or sharp objects, obtaining consent as appropriate.
- The MDS Nurse, DON, and Activity Staff conducted 1:1 smoking observation and risk evaluation for all residents who smoke; all 18 residents identified as requiring supervision during smoking.
- A new policy and procedure for Firearms and Other Weapons was initiated and scheduled for presentation to the Medical Director.
- Department head managers will conduct safety room checks during routine rounds to inspect for sharp objects, seizing and reporting any found to the Administrator.
- Facility Department heads will conduct weekly safety checks of resident belongings for 4 weeks, then monthly for 3 months, then quarterly, using the inventory form.
- Licensed Vocational Nurses and RN Supervisors will use shift huddles with CNAs to identify resident incompatibility and potential altercations, with immediate separation and reporting as needed; updated huddle form initiated.
- During weekends, the Manager of the Day will conduct rounds every 2 hours to identify incompatibility and potential altercations, reporting findings to Administrator/DON; RN Supervisor will monitor during night shifts and holidays.
- As part of Out on Pass procedure, the receptionist and licensed nurses will check any bags or items brought into the facility by residents or representatives to ensure no weapons or contraband are brought in.
- A new policy for Firearms and Other Weapons was initiated, reviewed, and approved by the Medical Director; in-service provided to staff on policy prohibiting weapons on facility premises.
- Administrator/designee will monitor and sustain the above processes, reporting trends and issues to the QAPI committee monthly for 3 months or until 100% compliance is achieved.
Failure to Protect Resident Privacy and Confidentiality of Medical Records
Penalty
Summary
The facility failed to protect the confidential personal and medical information of four residents by leaving sensitive documents and electronic records unattended and accessible to unauthorized individuals. Specifically, a narcotic medication sheet containing personal information for one resident was left in a bin at the nurse station, facing the hallway, making it visible to visitors, other residents, and staff not involved in the resident's care. This was confirmed during an observation and interview with a registered nurse, who acknowledged that the information was accessible to unauthorized persons. Additionally, the clinical records of three other residents were left open and unattended on a computer at the same nurse station. The computer screen displayed these residents' clinical information and was left logged in under the credentials of a nurse from a previous shift. This allowed the information to be potentially accessed by other staff not involved in the residents' care, as well as visitors and outside agencies, as observed and confirmed by the registered nurse present at the time. The residents involved had various medical diagnoses, including type 2 diabetes mellitus, essential hypertension, muscle weakness, and anxiety disorder. Their cognitive abilities ranged from intact to moderately impaired, as documented in their Minimum Data Set assessments. The facility's own policy required that only authorized personnel with proper credentials access electronic medical records, and that safeguards be in place to prevent unauthorized access, but these procedures were not followed in the incidents described.
Failure to Ensure Timely and Documented Physician Visits
Penalty
Summary
The facility failed to ensure that required face-to-face visits by a physician or alternate visits by a nurse practitioner (NP) were conducted in a timely manner for three of four sampled residents. According to the facility's policy and federal regulations, residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Documentation for these visits was either missing or did not indicate that the required physician visits occurred as scheduled. For one resident admitted with cellulitis, type 2 diabetes mellitus, and muscle weakness, the records showed an NP visit but no evidence of a physician visit after the initial assessment. Another resident admitted with type 2 diabetes, cystitis, and depression had documentation of an NP visit at admission, but no subsequent physician or NP visits were recorded. A third resident with type 2 diabetes, hypertension, and anxiety disorder had gaps in documentation, with no attending physician or NP notes for two consecutive months. Interviews with nursing staff and the DON confirmed that there was no documented evidence of timely physician visits or progress notes in the residents' medical records. The facility's policies require timely documentation of physician visits and progress notes, but these were not present in the records reviewed, indicating that the required assessments and documentation were not completed as per policy and regulatory requirements.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for three residents, as required by federal regulations. Specifically, physician telephone orders for two residents were not dated and signed, and the attending physician did not review and sign the order summaries for three residents on a monthly basis. Additionally, one resident's medical record contained blank worksheet forms and blank consent forms that had been signed by a nurse practitioner. These deficiencies were identified through record reviews and staff interviews, which confirmed that the required signatures and documentation were missing from the residents' medical records. For one resident admitted with cellulitis, type 2 diabetes mellitus, and muscle weakness, the physician's orders for pain medications were not signed or dated, and the order summary lacked the physician's signature for the relevant period. Another resident, admitted with type 2 diabetes mellitus, cystitis, and depression, had no printed and signed order summary in the medical record, and several blank forms and consents were found with a nurse practitioner's signature. A third resident, with chronic obstructive pulmonary disease, epilepsy, and depression, also had unsigned and undated physician telephone orders, and the order summary was not signed for the required months. Interviews with nursing and health information staff confirmed that the facility's policies required timely physician review and authentication of orders, as well as complete and accurate documentation in the medical record. Staff acknowledged that the missing signatures and incomplete records had the potential to result in unapproved or inaccurate orders and care. The facility's own policies and procedures were not followed, leading to incomplete and inaccurate medical records for the affected residents.
Failure to Thoroughly Investigate Resident Altercation Involving Weapon
Penalty
Summary
The facility failed to thoroughly investigate a resident-to-resident altercation involving two residents in the smoking patio, resulting in one resident injuring the other with a knife. Both residents had significant psychiatric and physical diagnoses, including dementia, schizophrenia, depression, anxiety disorder, and hemiplegia. The incident occurred when both residents, each in a wheelchair, engaged in a verbal argument that escalated to physical contact, culminating in one resident using a knife to injure the other. Video surveillance confirmed the sequence of events, and it was noted that no staff were present in the smoking patio during the altercation. The investigation into the incident was incomplete. The administrator acknowledged that she did not request surveillance footage from all available cameras to track the residents' movements after the altercation. Additionally, the location of the knife used in the incident remained unknown, as searches of the resident, the smoking patio, common areas, and the resident's room did not yield the weapon. The administrator admitted that the investigation was not thorough, and the facility's policy required all allegations to be thoroughly investigated, with supporting documents and evidence provided to the individual in charge of the investigation. The facility's failure to conduct a comprehensive investigation and to account for the weapon used in the altercation placed residents at risk for further abuse. The lack of staff supervision in the smoking patio at the time of the incident was also confirmed by video review. The administrator's statements and the documentation reviewed indicated that the facility did not meet the regulatory requirements for investigating and preventing further potential abuse during the investigation process.
Plan Of Correction
F 610 Maclay Healthcare Center makes every effort to comply with the State and Federal regulations. Nothing in this plan of correction is an admission otherwise. Maclay Healthcare Center submitted this plan of correction to comply with the State and Federal regulations and does not waive any objection obtained. This plan of correction is our credible allegation of compliance for deficiency noted findings of the California Department of Public Health during the Facility reported incidents survey completed on 3/22/25.
Failure to Complete Accurate PASARR Level I Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I Screening was properly completed for one of four sampled residents. The PASARR Level I Screening, dated 7/12/2024, indicated that the resident did not have serious mental diagnoses and did not require a Level II Screening. However, subsequent reviews of the resident's admission records, diagnosis worksheets, Minimum Data Set (MDS) assessments, and psychiatric evaluations revealed multiple mental health diagnoses, including anxiety disorder, schizophrenia, psychosis, depression, and episodes of delusions and hallucinations. The resident's admission record listed diagnoses such as anxiety disorder, schizophrenia, hemiplegia, and hemiparesis following a cerebral infarction. The MDS assessments and care plan further documented ongoing mental health issues, including anxiety disorder, depression, and psychosis. Despite these documented conditions, the initial PASARR Level I Screening did not reflect the resident's mental health status, and a Level II Screening was not initiated as required. Interviews with facility staff, including the MDS Specialist and the DON, confirmed that the PASARR Level I Screening should have been completed or updated to reflect the resident's psychiatric diagnoses. The facility's policy also indicated that a status change Level I PASARR screening should be completed if there is a change in psychiatric diagnoses or a discrepancy between PASARR and physician diagnoses. The failure to complete an accurate PASARR Level I Screening had the potential to delay necessary care and services for the resident.
Plan Of Correction
Maclay Healthcare Center makes every effort to comply with the State and Federal regulations. Nothing in this plan of correction is an admission otherwise. Maclay Healthcare Center submitted this plan of correction to comply with the State and Federal regulations and does not waive any objection obtained. This plan of correction is our credible allegation of compliance for deficiency noted findings of the California Department of Public Health during the Facility reported incidents survey completed on 3/22/25.
Medication Storage Policy Violation
Penalty
Summary
The facility failed to implement its policy and procedure on safeguarding prescribed medications for one of the sampled residents. Specifically, the facility did not ensure that a resident's prescribed medication was stored in the medication cart or the locked medication room. Instead, the medication was found in an unlocked drawer at the nurse station, which was accessible to unauthorized individuals. This oversight was identified during an observation and interview with a Licensed Vocational Nurse (LVN), who confirmed that the medication should have been stored securely. The resident involved was admitted with diagnoses including type 2 diabetes mellitus, essential hypertension, and depression, and their cognitive skills were intact. During a review of the resident's medical records, it was noted that there was no physician order for the dietary supplement found in the drawer, and the LVN acknowledged that discontinued medications should be disposed of properly. The Director of Nursing also confirmed that the facility failed to adhere to its medication storage policy, which requires all drugs to be stored securely and locked when not in use.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not following physician orders. The resident, who was admitted with diagnoses including metabolic encephalopathy, COPD, and muscle weakness, had intact cognitive skills according to the Minimum Data Set. During an observation, it was noted that the resident's medication box indicated a dosage of Atrovent inhaler that did not match the physician's orders. The medication label showed one puff every 24 hours, while the physician's orders required four puffs every 24 hours as needed for shortness of breath, wheezing, or COPD. The Licensed Vocational Nurse (LVN) confirmed that the resident had not received any dose of Atrovent since readmission from the hospital. The Director of Nursing (DON) acknowledged that the Registered Nurse (RN) did not verify the medication dosage and frequency with the attending physician, leading to the potential for the resident to receive the wrong dose. The facility's policy requires that any unclear or confusing medication orders be clarified with the attending physician before processing, which was not adhered to in this case.
Failure to Account for Controlled Substance Medication
Penalty
Summary
The facility failed to maintain a comprehensive system for pharmaceutical services, specifically in the management of controlled substances, which led to the inability to account for the whereabouts of a resident's narcotic medication. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted with diagnoses including aftercare following surgery for neoplasm, muscle weakness, and general anxiety disorder, had a physician's order for Lorazepam, a controlled substance, to be administered at bedtime for anxiety. During an interview, a Licensed Vocational Nurse (LVN) explained the procedure for verifying narcotics counts at the start of each shift, which involves both incoming and outgoing nurses signing off on the count. However, the facility's Director of Nursing (DON) revealed that an internal investigation found that the resident's narcotic medication and the corresponding count sheet were missing, and the exact number of missing tablets could not be determined. This indicates a failure in the facility's system to track and document the handling of controlled substances accurately. The facility's policy on controlled substances mandates compliance with laws and regulations regarding the handling, storage, disposal, and documentation of such medications. The policy outlines a system for reconciling the receipt, dispensing, and disposition of controlled substances, including maintaining records of personnel access, medication administration, inventory, and destruction or return to pharmacy records. Despite these policies, the facility did not adhere to them, resulting in the unaccounted loss of the resident's medication.
Failure to Honor Resident's Preference for Self-Administration of Medication
Penalty
Summary
The facility failed to honor a resident's preference to self-administer a medication, which was identified as a deficiency affecting the resident's sense of self-worth and self-esteem. The resident, admitted with diagnoses including type 2 diabetes mellitus, depression, and essential hypertension, had intact cognitive skills as per the Minimum Data Set. Despite the resident's preference to self-administer Trulicity, a medication for diabetes, the facility did not have an order allowing this, and the medication was administered by clinicians instead. Interviews with nursing staff revealed that the resident's preference to self-administer the medication was communicated to the registered nurse, but no assessment or care plan was initiated to evaluate the resident's ability to self-administer safely. The Director of Nursing acknowledged that the process to determine the resident's ability to self-administer should have been initiated upon learning of the resident's preference. The facility's policy indicated that residents have the right to self-administer medications if deemed clinically appropriate by the interdisciplinary team, but this process was not followed in this case.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to conduct a comprehensive assessment for a resident regarding their ability to self-administer medication. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, depression, and essential hypertension, had intact cognitive skills as per the Minimum Data Set. Despite this, the facility did not reassess the resident for self-administration of Trulicity, a medication used for diabetes management, as required by the facility's policy. The resident preferred to self-administer the medication, and a Licensed Vocational Nurse (LVN) allowed this to occur without a proper assessment or physician's order. The Director of Nursing (DON) confirmed that the facility's policy required a licensed nurse to assess and document a resident's ability to self-administer medication, which was not done in this case. The facility's policy also required the interdisciplinary team to evaluate the resident's cognitive and physical abilities to ensure it was safe and clinically appropriate for them to self-administer medications. The lack of assessment and documentation placed the resident at risk for medication administration errors, including potential infection and complications from incorrect administration.
Failure to Implement Care Plan for Self-Administration of Medication
Penalty
Summary
The facility failed to create and implement a comprehensive, person-centered care plan for a resident who was admitted with diagnoses including type 2 diabetes mellitus, depression, and essential hypertension. The resident's Minimum Data Set indicated intact cognitive skills, and physician orders specified the administration of Trulicity for diabetes management. However, there was no order for the resident to self-administer this medication, and no care plan was developed to address the resident's self-administration of medication. Interviews with facility staff, including a registered nurse, a licensed vocational nurse, and the Director of Nursing, revealed that the facility did not follow its policy and procedure on self-administration of medication. The policy required an assessment of the resident's ability to self-administer medication, education, and a physician order, followed by the creation of a care plan. The absence of a care plan for self-administration of medication placed the resident at risk for inconsistent care and potential complications from incorrect medication administration.
Lack of Physician Order for Self-Administration of Diabetes Medication
Penalty
Summary
The facility failed to ensure that a resident had a physician order to self-administer Trulicity, a medication used for treating type 2 diabetes mellitus. The resident was admitted with diagnoses including type 2 diabetes, depression, and essential hypertension. The Minimum Data Set indicated that the resident's cognitive skills were intact. However, the physician orders specified that licensed nurses were to administer the Trulicity, and there was no order for the resident to self-administer the medication. Interviews with the nursing staff and the Director of Nursing confirmed the absence of a physician order for self-administration. The facility's policy and procedure on self-administration of medications require a physician order and an interdisciplinary team assessment to determine if it is clinically appropriate and safe for a resident to self-administer medications. Despite this policy, the facility did not have documented evidence of such an order or assessment for the resident in question. This oversight had the potential to create confusion in the delivery of care and services to the resident.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not following physician orders. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, depression, and essential hypertension, was allowed to self-administer Trulicity, a medication for diabetes, without a physician's order. The resident's cognitive skills were intact, as indicated by the Minimum Data Set, but there was no documented order permitting self-administration of the medication. Interviews and record reviews revealed that the resident self-administered Trulicity on multiple occasions, despite the absence of a physician's order. A Licensed Vocational Nurse confirmed that the resident preferred to self-administer the medication and did so seven out of eight times when the nurse was assigned to administer it. The Director of Nursing acknowledged that self-administration required a physician's order, which was not obtained, and that the facility failed to adhere to its policy and procedure regarding self-administration of medications. The facility's policy required an interdisciplinary team assessment to determine if self-administration was clinically appropriate and safe, which was not conducted in this case.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse when an altercation occurred between two residents. On December 3, 2024, Resident 2 hit Resident 1 on the left arm, causing a scratch, after Resident 1 had wheeled herself close to Resident 2 and repeatedly said 'amen.' Resident 7, who witnessed the incident, reported that Resident 2 told Resident 1 to stop, but when Resident 1 did not, Resident 2 retaliated by hitting Resident 1. This incident was classified as physical abuse according to the facility's policy and procedure. Resident 1, admitted on April 27, 2024, had a diagnosis of saddle embolus of the pulmonary artery with acute cor pulmonale and moderate cognitive impairment. Resident 2, initially admitted on October 8, 2012, had a diagnosis of hemiplegia following a cerebral infarction and severe cognitive impairment. The facility's policy, last reviewed in April 2024, emphasizes the residents' right to be free from abuse, including physical abuse by other residents. The incident was confirmed as abuse by both a Licensed Vocational Nurse and the facility Administrator during interviews.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of employee-to-resident abuse within the required two-hour timeframe to the State Survey Agency, the Ombudsman, and law enforcement. This incident involved a resident who was admitted with a displaced intertrochanteric fracture of the right femur, dysphagia, and essential hypertension. The resident's cognitive skills for daily decisions were severely impaired, and they required moderate assistance for activities of daily living. On the night of the incident, the resident was reportedly rough-handled by a Certified Nursing Assistant (CNA), who allegedly hit the resident in the head with a dirty incontinent brief. The incident was initially reported by a Licensed Vocational Nurse (LVN) who heard the resident yelling and screaming. The LVN contacted a family member to translate the resident's complaints due to a language barrier. The family member relayed that the CNA was rough and had hit the resident. The LVN reported this to a Registered Nurse (RN), who failed to notify the Director of Nursing, the Administrator, or the appropriate authorities that night. Instead, the RN reported the incident the following day to the Director of Staff Development and the Assistant Director of Nursing. Interviews with facility staff, including the Assistant Director of Nursing and the Administrator, confirmed that there was a delay in reporting the allegation of abuse. The facility's policy requires that any allegation of abuse be reported within two hours to initiate an investigation and ensure resident safety. The failure to adhere to this policy resulted in a deficiency, as the incident was not reported to the necessary authorities in a timely manner, potentially placing the resident at risk for further abuse.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, which is a deficiency in accordance with accepted professional standards of practice. The resident was admitted with diagnoses including a displaced intertrochanteric fracture of the right femur, dysphagia, and essential hypertension. A discrepancy was noted between the resident's History and Physical, which indicated the resident had the capacity to understand and make decisions, and the Minimum Data Set, which showed the resident's cognitive skills for daily decisions were severely impaired. Additionally, the resident required moderate assistance for activities of daily living and was always incontinent of bowel and bladder functions. An incident occurred where the resident was reportedly yelling and upset, leading to a call to a family member for translation due to a language barrier. The family member translated that a CNA was rough with the resident and allegedly hit the resident in the head with a dirty incontinent brief. This incident was not accurately documented in the resident's medical record, as noted by the Assistant Director of Nursing during a review. The facility's policy requires that medical records be complete and accurate, including documentation of events, incidents, or accidents involving the resident.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. On the evening of October 17, 2024, a Certified Nursing Assistant (CNA) witnessed one resident physically assaulting another resident in their shared room. The aggressor placed an arm around the victim's neck and repeatedly punched the victim in the face while the victim was seated in a wheelchair watching television. This incident resulted in the victim sustaining swelling, bleeding, and pain in the lips. The victim, identified as having severely impaired cognition and a history of cerebrovascular disease, was admitted to the facility in September 2024. The victim's Minimum Data Set (MDS) indicated a lack of interest in activities and feelings of depression and hopelessness. The Change in Condition Evaluation documented the physical abuse and the subsequent medical response, including notifying the attending physician and applying an ice pack to the victim's swollen lip. The aggressor, admitted in March 2021, had a history of aggressive behavior and was diagnosed with conditions including encephalopathy and paranoid schizophrenia. The aggressor's care plan included interventions for managing aggressive behavior, but these measures failed to prevent the incident. Interviews with facility staff, including the CNA and the Director of Nursing, confirmed the occurrence of physical abuse and acknowledged the facility's failure to prevent it. The facility's policy on abuse prevention was reviewed, highlighting the residents' right to be free from abuse by anyone, including other residents.
Failure to Provide Safe and Homelike Environment Due to Plumbing Issues
Penalty
Summary
The facility failed to provide a safe and homelike environment for four residents due to plumbing issues in their restrooms. Residents 1, 2, and 3 were affected by clogged drains in their rooms, which were not resolved promptly. The Director of Maintenance and Maintenance Assistant attempted to unclog the drains but were unsuccessful, resulting in stagnant water in the shower rooms. This situation forced the residents to use alternative restrooms, which were not adequately prepared or communicated to them. Resident 4 was not informed that other residents were directed to use their restroom, compromising their privacy. Interviews with staff revealed a lack of communication and planning regarding the use of alternative restrooms. Certified Nursing Assistants and a Licensed Vocational Nurse were not informed about where to assist residents with their toileting needs, leading to confusion and potential privacy violations. Residents expressed inconvenience and safety concerns about using restrooms in other residents' rooms or the staff restroom, which required a code and was not accessible for those using walkers or wheelchairs. The Director of Nursing was unaware of the situation and acknowledged that the facility failed to provide a homelike environment and ensure resident safety and privacy. The facility's policy on providing a homelike environment was not followed, as residents were not offered temporary room changes or alternative solutions like commodes. The facility's failure to address the plumbing issue and communicate effectively with residents and staff resulted in a deficiency in maintaining a safe and comfortable environment.
Failure to Prevent Allergen Exposure in Resident's Meal
Penalty
Summary
The facility failed to ensure that a resident with a known allergy to onions was not served food containing this allergen. On a specific date, the resident was served baked beans that contained onions, despite their allergy being documented in their medical records, care plan, and meal tray ticket. The resident's care plan explicitly stated that they should not be served food containing onions, and the meal tray ticket indicated the resident's dietary restrictions, including their allergy to onions. During the meal tray preparation process, the dietary staff did not adhere to the facility's policies and procedures regarding food allergies. The dietary aide announced the resident's diet and allergies, but the meal tray still contained baked beans with onions. The dietary supervisor and licensed nurses checked the meal trays for accuracy, but the presence of onions in the baked beans was not identified. The resident, aware of their allergy, did not consume the beans and expressed concern about the potential presence of onions. Interviews with the dietary staff revealed a lack of awareness about the ingredients in the baked beans, as the recipe used included onions. The cook admitted to using onion powder instead of chopped onions, which was not communicated during the initial interview. The facility's policies required that residents with food allergies be offered appropriate substitutions and that meals be prepared to prevent exposure to allergens, which was not followed in this instance.
Removal Plan
- Resident 135 was assessed by a licensed nurse for signs and symptoms of food allergies. No allergic reaction was observed.
- The DON notified Resident 135's primary physician indicating the resident was mistakenly served food containing onions.
- The Dietary Supervisor visited Resident 135 to discuss the resident's food allergies and food preferences.
- The Dietary Supervisor conducted a review of all current resident's medical records residing in the facility with noted food allergies and there were no issues found.
- The Dietary Supervisor conducted an in-service with all dietary staff on the facility's Food Allergy Policy which included implementing colored meal tray card and reviewing menu or recipe to offer substitutes addressing food allergies.
- For higher visibility, green meal tray cards indicating food allergies were created for residents with food allergies.
- Residents with food allergies were provided a green non-removable arm band with their names and food allergies.
- The Director of Staff Development provided an in-service to the licensed nurses and Certified Nursing Assistants which included the green non-removable arm bands as visual identifier for residents who have food allergies.
- The Registered Dietitian reviewed current residents' medical records to ensure food allergies are up to date.
- The Registered Dietitian conducted a one to one in-service with the Cooks and the Dietary Supervisor regarding the facility policy on food allergies, food likes or dislikes, menu, recipes, and to accommodate food item substitution to address food allergies.
- Before the breakfast service, the Registered Dietitian, the Cooks, and the Dietary Supervisor conducted kitchen huddles on menu, recipes, and meal substitution for residents with food allergies.
- A list of residents and their food allergies will be posted in the kitchen meal preparation area to allow dietary staff to easily identify all residents' food allergies. The list of residents and their food allergies will be written in English and Spanish. Identified residents with food allergies will be served alternate meals.
- The facility will implement a new menu system called Menus 2U which integrates Electronic Health Records and ensures that all new dietary orders and food allergies are automatically entered into the facility's EHR. The software will include printing of the updated diet slip for each meal by the Dietary Supervisor or designee and the dietary staff will reference the meal preparation during meal tray line, avoiding inaccuracies, and identifying allergies.
- The Dietary Supervisor or designee will conduct a daily review of all current residents' medical records to ensure that residents with food allergies are included on the allergy list visibly posted during the meal tray line process.
- The Dietary Supervisor or designee will conduct daily huddles with all dietary staff in English and Spanish to discuss current residents with food allergy to ensure meals that will be served will not contain food allergies.
- The Dietary Supervisor or designee will conduct daily meal tray audit for allergies using the Tray line Supervisory Inspection Log every breakfast, lunch, and dinner meals and every 10 a.m., 2 p.m., and 8 p.m. snacks.
- Licensed Nurses shall check meal trays for any food allergies, food dislikes, and preferences before serving the residents. Any discrepancy in accuracy on the meal prepared in comparison with the diet slip will be returned to the kitchen by the licensed nurse for correction and replacement.
- The Dietary Supervisor will conduct a review of food preferences and allergies upon admission, readmission, quarterly, and as needed. The Health Information Department will conduct an audit monthly to validate this process. Audit findings will be forwarded to the DON and to the Administrator for further follow through.
- The Registered Dietitian will conduct monthly review of residents with food allergies and update the list of residents and their food allergies as needed.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the actions of LVN 6. LVN 6 did not knock or request permission before entering Resident 68's room and loudly stated the resident's name, which was audible from 35 feet away. This behavior was observed during a survey, and LVN 6 admitted to leaving medications at the bedside for Resident 68 to self-administer, despite knowing it was against policy. Resident 68 expressed feeling disrespected by LVN 6's actions, and other residents also reported unprofessional behavior from LVN 6 during a Resident Council interview. Additionally, the facility failed to maintain resident privacy for Resident 83. CNA 8 undressed Resident 83 in a manner that made the resident visible from the hallway, compromising the resident's privacy. CNA 8 acknowledged that the resident should have been undressed behind a privacy curtain to protect their dignity. The Director of Nursing confirmed that residents should be provided bodily privacy during personal care, and the facility's policy supports this requirement. The facility's policies on resident rights and quality of life emphasize treating residents with dignity and respect, ensuring privacy, and promoting a sense of well-being. However, the actions of LVN 6 and CNA 8 violated these policies, leading to deficiencies in the care provided to Residents 68 and 83. These practices had the potential to negatively impact the residents' psychosocial well-being and quality of life.
Failure to Conduct Restraint Assessments and Obtain Consents
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, as evidenced by the cases of three residents. For Resident 75, the facility did not complete a restraint assessment before using a sensor pad alarm, which was intended to alert staff when the resident attempted to get out of bed unassisted. The sensor pad alarm was considered a restraint because it restricted the resident's freedom of movement, yet no assessment was conducted to determine its appropriateness. Additionally, the alarm was found turned off, which could have prevented staff from being alerted to the resident's movements. In the case of Resident 116, the facility placed the resident's bed against the wall without obtaining a physician's order, informed consent, or completing a restraint assessment. This action was considered a restraint as it restricted the resident's ability to get out of bed from one side. The facility's policy required a pre-restraining assessment and informed consent, which were not obtained, and the intervention was not included in the resident's care plan. Similarly, for Resident 66, the facility placed the bed against the wall without a physician's order, restraint assessment, informed consent, or care plan. This practice was also considered a restraint, as it restricted the resident's movement. The facility's policy clearly stated that such practices are not permitted without proper assessment and documentation, which were lacking in this case.
Failure to Implement Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with chronic respiratory failure, depression, and atrial fibrillation, had orders for oxygen therapy, psychotropic medications, and an anticoagulant. Despite these orders, no baseline care plans were created to address the use of oxygen therapy, Donepezil, Mirtazapine, Trazadone, and Warfarin. This oversight was identified during a review of the resident's records, including the Admission Record, Order Summary Report, and Medication Administration Record. Interviews with the Registered Nurse and the Director of Nursing confirmed the absence of baseline care plans for the resident's treatments. Both acknowledged that care plans should have been developed to provide a structured framework for addressing each intervention, including setting goals and monitoring progress. The facility's policy, last reviewed in April 2024, mandates that a baseline plan of care be developed for each resident within 48 hours of admission to meet their immediate needs. The lack of such plans had the potential to delay care and treatment, thereby decreasing the resident's quality of life.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. For Resident 102, the facility did not create a care plan for medication storage at the bedside, despite the resident having medications like gas relief medication and artificial tears eye drops at the bedside without approval for self-administration. The Minimum Data Set Director confirmed that Resident 102 was not granted approval to self-administer medications, and the Director of Nursing acknowledged the necessity of a care plan to guide staff interventions. Resident 107's care plan lacked focus on the use of bed rails, which were ordered as an enabler for mobility. The resident, who had difficulty understanding and making decisions, used the bed rails daily. The Director of Nursing stated that a care plan should have been developed to guide staff on providing interventions related to bed rail use. Similarly, Residents 17 and 23 had care plans for activities of daily living that were not implemented. Resident 17 was observed with facial hair, contrary to the care plan's interventions for personal hygiene, and Resident 23 was not dressed in personal clothing as preferred, despite having clothes available. The facility also failed to develop and implement care plans for the use of medications. Resident 66 was prescribed Mirtazapine, an antidepressant with a black box warning, but there was no care plan addressing its use. The Director of Nursing emphasized the importance of a care plan to monitor the medication's effects. Additionally, Resident 75, who had type two diabetes mellitus and was receiving insulin, did not have a care plan addressing diabetes management and insulin use. The Minimum Data Set Nurse and Director of Nursing both noted the absence of a care plan, which is crucial for evaluating intervention effectiveness and preventing delays in care.
Failure to Rotate Injection Sites for Insulin and Enoxaparin
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards of care by not rotating subcutaneous injection sites for insulin and enoxaparin administration for two residents. Resident 70, who was admitted with type 2 diabetes mellitus and a history of surgical amputation, received insulin and enoxaparin injections without proper site rotation. The review of the resident's records from August to October 2024 revealed multiple instances where injections were administered repeatedly in the same areas, contrary to the facility's policy and procedure for insulin administration. Similarly, Resident 75, diagnosed with type 2 diabetes mellitus, generalized muscle weakness, and dementia, also received insulin injections without appropriate site rotation. The resident's medication administration records from September to October 2024 showed repeated use of the same injection sites, which was confirmed by the Minimum Data Set Nurse. The facility's policy and procedure, as well as the manufacturer's guidelines, clearly indicated the necessity of rotating injection sites to prevent tissue damage. Interviews with the Registered Nurse and the Director of Nursing confirmed the failure to rotate injection sites for both residents. The Director of Nursing acknowledged that this oversight placed residents at risk for adverse effects such as bruising and lipodystrophy. The facility's policy on adverse consequences and medication errors defined such practices as medication errors, highlighting the deviation from accepted professional standards and physician's orders.
Facility Fails to Maintain Safe Environment and Medication Management
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for several residents. For Residents 66, 75, and 114, fall mats intended to reduce injury risk were compromised by having heavy furniture placed on them, which could lead to permanent indentations and reduced effectiveness in cushioning falls. Observations revealed that bedside tables were placed on these mats, making them unstable and potentially dangerous if they were to fall on the residents. Interviews with staff confirmed that such practices were against the facility's policies and could lead to increased risk of injury. Additionally, the facility did not adequately manage medication safety for Residents 70, 80, 102, 103, and 68. Medications were found unattended at residents' bedsides, despite assessments indicating that these residents were not approved to self-administer their medications. This oversight could lead to medication errors such as overdosing or underdosing, and accidental ingestion by other residents. Staff interviews highlighted a lack of adherence to the facility's policies regarding medication storage and administration. Furthermore, Resident 96's environment was not maintained safely, as a wet floor was left unattended after a CNA provided assistance with activities of daily living. This oversight posed a slip and fall risk for the resident, who was known to be at high risk for falls. The facility's policies emphasize the importance of maintaining a hazard-free environment, yet these incidents demonstrate a failure to adhere to these standards, potentially compromising resident safety.
Failure to Document Dialysis Weights
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care consistent with professional standards. Specifically, the facility did not document pre and post dialysis weights for a resident with end-stage renal disease (ESRD) who was dependent on renal dialysis. The resident, who was capable of understanding and making decisions, had an order for weights to be taken on dialysis days, twice a day every Tuesday, Thursday, and Saturday. However, the weight summary showed that weights were only documented on a few scattered dates, not in accordance with the prescribed schedule. Interviews with the Minimum Data Set Director (MDSD) and the Director of Nursing (DON) confirmed that the weights were not documented in the Medication Administration Record (MAR) or the weight summary as required. The facility's policy indicated that weights should be recorded in the individual's medical record, but this was not followed. The lack of documentation hindered the facility's ability to monitor the resident's weight changes, which are crucial for managing dialysis treatment effectively.
Improper Bed Rail Use and Assessment Deficiencies
Penalty
Summary
The facility failed to properly assess and manage the use of bed rails for several residents, leading to potential safety risks. For Resident 66, the facility did not discontinue the use of bed rails despite an assessment indicating they were not needed. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was observed with bed rails up, contrary to the Bed Rail Entrapment Risk Evaluation. The Director of Nursing (DON) confirmed that the continued use of bed rails without appropriate assessment could lead to accidents such as entrapment. Similarly, Resident 90, who had severe cognitive impairment and was at high risk for falls, was observed with bed rails up despite an evaluation indicating they were not needed. The facility failed to conduct a quarterly assessment to evaluate the necessity of the bed rails and did not obtain informed consent for their continued use. The DON acknowledged that the lack of assessment and consent posed a risk of injury to the resident. For Resident 75, the facility used half side rails as a restraint without completing a restraint assessment, obtaining a physician's order, or informed consent. The resident, who had moderately impaired cognition and was at high risk for falls, was observed with the incorrect type of side rails, which were considered a restraint. The DON confirmed that the facility should have followed proper procedures to ensure the appropriateness of the intervention. Additionally, Resident 107's informed consent for bed rail use was missing from the medical record, which the DON stated was a violation of the resident's rights.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 2,815 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sylmar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grove Post-acute Care Center | 1.1 mi | — | 39 | 0 |
| Mountain View Conv Hosp | 1.2 mi | — | 40 | 0 |
| Astoria Healthcare Center | 1.4 mi | — | 17 | 2 |
| Country Manor Healthcare | 2 mi | — | 26 | 0 |
| Ararat Nursing Facility | 2.6 mi | — | 14 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.