Madera Post Acute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Monte, California.
- Location
- 11900 Ramona Boulevard, El Monte, California 91732
- CMS Provider Number
- 055141
- Inspections on file
- 55
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 43 (1 serious)
Citation history
Health deficiencies cited at Madera Post Acute Center during CMS and state inspections, most recent first.
Two residents with diabetes, mobility limitations, and one with dysphagia reported that staff often took about 30 minutes to respond to call lights, with delays worse on weekends and at night, particularly when toileting and cleaning assistance was needed. Both residents were cognitively intact, and one was fully dependent on staff for toileting and lower body care. The DON acknowledged that prompt call light response is essential for residents dependent on staff, while facility policies require residents to be treated with dignity and call lights to be answered within a reasonable time.
A resident with pancytopenia, muscle weakness, and acute kidney failure developed a fever and burning pain with urination and reported these symptoms to staff. Nursing staff documented the change in condition on an INTERACT CIC form and recorded that the physician was notified and that they were awaiting orders, but in reality an LVN only sent text messages to the physician and never received a response. The DON’s review of text records confirmed there was no reply, and neither the physician nor associated NP were aware of the change in condition. Staff acknowledged that, per facility policy, they should have escalated to the Medical Director when the attending MD could not be reached, but this did not occur, resulting in a failure to promptly notify a provider of the resident’s condition.
A resident with diabetes, major depressive disorder, and a prior left femoral neck fracture, who was dependent for most ADLs, had a care plan requiring the bed to be kept in the lowest position to reduce fall risk. A change in condition note documented the resident being found on the floor beside the bed. Surveyors later observed the bed not in the lowest position on multiple occasions. A CNA stated the resident needed supervision for bed mobility and transfers and acknowledged the bed was not kept in the lowest position. The resident reported falling while attempting to transfer from a wheelchair that was too far from the bed and stated the bed was not in the lowest position at the time. The DON confirmed the resident was at high risk for falls and that facility policy and the care plan required supervision, the bed in the lowest position, and the call light within reach.
A resident with pancytopenia, muscle weakness, and acute kidney failure developed fever and burning pain with urination and reported these symptoms to staff. An LVN completed a change in condition evaluation indicating that the resident’s MD had been notified and that staff were awaiting orders. However, the LVN had only sent text messages to the MD and received no response, later admitting the documentation was incorrect. The DON confirmed via text message screenshots that no reply was received and that, under the facility’s practice, this meant the MD had not actually been notified, resulting in an inaccurate medical record entry.
Nursing staff failed to promptly respond to call lights for two residents who required supervision to extensive assistance with ADLs, including one with a history of falls and muscle weakness and another with paraplegia and incontinence. Both residents reported waiting 15–25 minutes for assistance, particularly during evening and night shifts, with one resident remaining soiled while waiting for help. Resident council minutes also reflected concerns about slower call light response at night. The DON stated that all staff are expected to answer call lights as soon as possible, and facility policy requires call lights to be answered within a reasonable time.
Surveyors found that the facility did not develop complete, person-centered care plans for two residents. One resident with an above-the-knee amputation, a right foot fracture, cognitive impairment, and documented PT orders for maximum, two-person assistance with transfers had a care plan that only stated transfers with staff participation and did not specify the required two-person assist. Another resident with cancer diagnoses and an abdominal biliary drain tube had physician orders for routine flushing of the drain, but there was no corresponding care plan addressing the biliary drain, including monitoring and management. The DON acknowledged that both the transfer assistance and biliary drain use should have been incorporated into the residents’ care plans in accordance with the facility’s comprehensive care planning policy.
Facility staff, including the administrator, conducted a search of a resident's room for cigarettes and a lighter without the resident's consent or prior notification, despite documentation that the resident had decision-making capacity and was independent in most ADLs. After the resident was seen smoking on the patio and refused to surrender a lighter, the administrator involved the police and entered the resident's room to search for the lighter. The DON later acknowledged that staff could not search a resident's room without permission and that residents have a right to privacy, consistent with the facility's Resident Rights policy.
Surveyors found a box of 5% lidocaine patches labeled for a discharged resident stored on a shelf in an unsecured nursing supply shed accessible to many people, rather than in designated medication storage areas. The Director of Maintenance reported no knowledge of the medication and confirmed it should not be in the shed, while the DON stated that medications are to be stored only in med carts and medication rooms and that this placement, likely by a staff member, violated facility policy and created a risk of medication diversion.
A resident with DM, heart failure, and documented decision-making capacity was allowed to smoke without the facility completing required smoking evaluations in accordance with its P&P. Two smoking evaluation forms were left incomplete, lacking documentation of smoking frequency, smoking safety, care plan updates, and resident education on safe smoking practices, smoking risks, and designated smoking areas. Despite a care plan problem for noncompliance with the smoking policy and a noted change in condition, no reassessment of the resident’s smoking ability was found in the medical record. The MDS nurse and DON confirmed that smoking evaluations must be completed quarterly, annually, and with changes in condition, that all sections must be filled out or refusals documented, and that failure to do so could create smoking safety issues.
A resident with cerebral palsy, quadriplegia, dysphagia, severe cognitive impairment, and total ADL dependence had a GT and a physician’s order for 60 ml of water every hour for 20 hours daily for hydration. There was no enteral feeding pump in the room to deliver the ordered water, and both an LVN and the ADON reported that the hydration order had been overlooked. Another LVN stated they were unaware of the order, had never seen a feeding pump in the room, and acknowledged that multiple MAR entries indicating hourly water administration were incorrect, meaning the resident did not receive the prescribed GT hydration in accordance with the facility’s hydration policy.
The facility failed to follow its abuse reporting policy by not reporting multiple allegations of staff abuse and inappropriate conduct to the State Agency within the required timeframes. Cognitively intact residents with significant medical conditions reported or were involved in incidents where CNAs allegedly made sexually inappropriate comments, engaged in sexually suggestive gestures, and spoke aggressively and rudely, including telling a resident to shut up. Staff who became aware of these allegations delayed reporting them to administration, and an LVN acknowledged not reporting the allegations to the State Agency. The Administrator conducted an internal investigation of at least one allegation and decided it was not abuse, and therefore did not report it externally, despite the written policy requiring immediate reporting of all alleged violations.
Two residents at high risk for falls did not receive care consistent with the facility’s Fall Management System policy. For one resident with dementia and severe cognitive impairment, who had an order and care plan for a bed pad alarm when in bed, surveyors observed the resident sitting at the bed’s edge while the alarm device was switched off on the nightstand. For another cognitively impaired resident with multiple comorbidities and high ADL assistance needs, the IDT did not add new fall-prevention interventions after multiple falls, and the resident’s care plan was not updated to reflect these events.
Surveyors found that kitchen staff failed to follow facility P&Ps for labeling and dating refrigerated cheese products. In the walk-in refrigerator, shredded cheese, Parmesan cheese, and blocks of orange cheese were labeled with dates that did not specify whether they were open, use by, or expiration dates, and some items lacked a use by or expiration date altogether. The Dietary Supervisor, a dietary aide, and the administrator all acknowledged that food items should be labeled with clear use by or expiration dates to prevent use of expired food, and facility policies required all stored foods, including commercially processed ready-to-eat items, to be properly labeled and dated according to defined time frames.
A cracked floor in a hallway, observed by surveyors and reported as unsafe by several residents and staff, was not repaired or marked with warning signs. Residents with mobility impairments and fall risks were seen traversing the area, and facility records showed no maintenance reports or actions taken, despite the facility's policy requiring safe and well-maintained flooring.
A resident with respiratory failure and COPD did not receive continuous oxygen therapy as ordered by the physician. Records showed the resident was frequently on room air instead of oxygen, and observations confirmed the oxygen flow was set below the prescribed rate. Facility staff acknowledged the physician's order was not followed, contrary to facility policy.
A resident with multiple medical conditions and a high risk for falls was found to have their call light placed under their pillow, making it inaccessible when assistance was needed. The care plan and facility policy required the call light to be within reach, but staff failed to ensure this, as confirmed by both DON and an LVN during interviews.
The facility did not have infection control (IC) policies and procedures available at any of the four nurse's stations. Staff, including an LVN, RN, IPN, and ADON, were unable to locate the IC policy and procedure binder at their stations and confirmed that the documents were kept in the IPN's office instead. The DON stated that these policies should be accessible at all nurse's stations for staff to reference during infection control situations.
Staff at all four nursing stations, including RNs, the infection prevention nurse, and the ADON, were unable to locate the required name, address, and telephone number of local health officers. The DON confirmed this information was not available at any nursing station, preventing easy access to local health officer contact details.
Surveyors found that insulin pens for three patients were labeled with incorrect storage instructions, stating they should be refrigerated after opening, contrary to standard practice. Additionally, two patients' monthly physician order recapitulation reports were not signed and dated, as required. These deficiencies were identified through observation, interview, and record review.
Two residents with diabetes and cognitive impairments had monthly physician order recapitulation reports that were not properly signed or dated by the approving physician, as required by facility policy. The DON confirmed that the necessary physician signatures and dates were missing from the Order Summary Reports for multiple months.
The facility failed to ensure that two residents' medication and IV therapy administrations were properly documented as ordered. One resident's required monitoring for depression while on Zoloft was not recorded on several shifts, and another resident's D5NaCl IV therapy was not documented as administered on multiple days. These omissions resulted in incomplete medical records, as confirmed by the DON.
Two residents with cognitive impairment and significant care needs were found without wristband identification or any other means of identification, despite facility policy requiring such identification at all times. Facility staff, including the DSD and DON, confirmed the absence of wristbands and acknowledged the importance of identification for safe care and medication administration.
A resident with diabetes did not receive insulin as ordered when an LVN held multiple doses of Tresiba without a physician's order and failed to notify the physician. Additionally, another LVN administered Tresiba but did not document it in the MAR as required by facility policy.
Several residents with a history of smoking, including those with cognitive impairment and complex medical conditions, were found to have unsupervised access to cigarettes and lighters, despite care plans and facility policy requiring secure storage and supervision. Staff were unaware that residents possessed these items, and some residents were able to access smoking areas independently, bypassing required supervision.
Multiple residents were not provided adequate privacy during care, including exposure during medical procedures and uncovered drainage bags, and one resident was left in a soiled brief for several hours without being offered timely toileting assistance, despite being able to communicate their needs. Staff and facility policies confirmed these actions did not meet required standards for dignity and respect.
The facility did not ensure that each resident received an accurate assessment, as required. Inaccurate assessments were identified, which could affect care planning and service delivery for residents.
Four residents did not have comprehensive care plans developed or implemented to address their specific needs, including management of Buspirone for anxiety, chronic abdominal pain, recurrent UTIs, and Hydrocodone use for pain. Staff interviews and record reviews confirmed the absence of required care plans, despite facility policy and physician orders, resulting in a lack of guidance for staff in providing appropriate care and monitoring.
During meal service, 20 cups of thickened and boxed milk were left at room temperature, with temperatures measured above the required 41°F. The milk was removed from refrigeration and not placed on ice, contrary to facility policy, and staff did not monitor or maintain proper cold holding temperatures.
Staff failed to follow infection prevention and control policies by not labeling and properly storing a resident's urinal, not wearing required PPE during high-contact care for residents on Enhanced Barrier Precautions, not changing PPE between care of two residents, and not posting EBP signage or providing PPE carts for a resident with nephrostomy tubes. These actions were confirmed by staff interviews and policy review.
A resident's bedroom wall was found to be missing a baseboard, exposing drywall and peeling paint, which was confirmed by both the DON and Maintenance Supervisor. The resident, who had impaired cognition and required assistance with daily activities, was living in an environment that did not meet the facility's standards for cleanliness and homelike conditions as outlined in its policies.
A resident with a history of enterocolitis and irritable bowel syndrome experienced no bowel movement for four days and reported severe abdominal pain. Despite a clinical alert and facility policy requiring physician notification and documentation of a change in condition, staff did not assess or notify the physician. Nursing staff interviews revealed communication lapses and failure to act on alerts or reports from CNAs.
A resident with hemiplegia and right-sided paralysis was found with bilateral upper side rails in use without documented physician order or informed consent. The DON confirmed that neither the required order nor consent was present in the medical record, despite facility policy mandating these steps before bed rail installation.
A resident with hemiplegia and hemiparesis, who had a physician's order for a plate guard to assist with eating, was observed eating without the adaptive equipment, resulting in food spilling onto their blanket and clothes. Both an LVN and the DON confirmed the plate guard should have been provided as per the order and facility policy.
A resident with mobility impairments and orders for sensor pads in bed and wheelchair did not have a functioning wheelchair alarm, as observed during an equipment check. While the bed alarm worked, the wheelchair alarm failed to sound until a different alarm was used. Facility leadership confirmed there was no monitoring or policy in place to ensure alarm functionality, despite general equipment maintenance policies.
Nurse staffing information was only posted on a consumer board in a hallway, rather than in a prominent and accessible location for residents and visitors. The DSD confirmed responsibility for the posting and acknowledged that the current location was not accessible to all, including those using wheelchairs, despite facility policy requiring prominent and accessible posting.
A resident with hemiplegia and other medical conditions experienced an incident during transfer from a shower chair when their paralyzed leg became caught, but the CNA did not report the event to nursing staff. The resident later complained of pain, and although an RN administered Tylenol, no further assessment was documented until more severe symptoms appeared, leading to the discovery of a tibial fracture. The facility did not follow its policy for reporting and assessing significant changes of condition.
A resident with multiple chronic conditions was found with purplish discoloration on the right great toe, but staff failed to document how the injury occurred. Interviews indicated the injury happened during a shower when the resident struck their foot, but this was not recorded in the clinical record as required by facility policy. Nursing staff and the DON confirmed that complete documentation was necessary but was not done in this instance.
A resident with a history of diabetes and chronic kidney disease experienced increased swelling in the left leg and foot, but the LVN failed to notify the physician or complete a Change of Condition form as required by facility policy. This delay in communication resulted in a lack of timely medical intervention, putting the resident at risk for further complications. The DON confirmed the importance of prompt notification and monitoring according to the facility's policy.
A resident with diabetes and chronic kidney disease experienced increased swelling in the left leg and foot, but the LVN failed to complete necessary documentation or notify the physician, delaying care. The resident's condition worsened, leading to open toe wounds. The DON confirmed the oversight in following the facility's protocol for change of condition.
A CNA improperly applied ointments to a resident without a physician's order, contrary to facility policy and professional standards. The resident, at risk of skin breakdown, had ointments applied at the request of a family member. Interviews with an LVN and the DON confirmed that only licensed nurses should apply such treatments and that a physician's order is required.
A facility failed to report a verbal abuse incident involving a resident and a family member to the appropriate authorities within the required timeframe. The incident, witnessed by staff, involved derogatory language directed at a resident by a family member of another resident. Despite being informed, the DON did not report the incident, violating the facility's policy on reporting abuse.
A resident was prescribed Seroquel for false accusations towards staff without a proper psychiatric diagnosis, contrary to the facility's policy requiring specific conditions for psychotropic medication use. The resident's Minimum Data Set showed intact cognition, but a Change in Condition Evaluation noted confusion and hallucinations. The primary care provider and DON expressed concerns about the medication order's appropriateness, emphasizing the need for a thorough medical work-up and proper behavior monitoring.
The facility failed to ensure call lights were within reach for three residents at risk of falls. A resident with dementia had a tangled call light, another with severe cognitive impairment had a non-functional call light on the floor, and a third resident's call light was unreachable under the bed. These deficiencies were against the facility's policy and care plans, which required call lights to be accessible.
The facility failed to provide communication devices for two residents with language barriers, leading to potential communication issues and delayed care. One resident, with dementia and a cognitive communication deficit, spoke Mandarin but lacked a communication board. Another resident, with osteoarthritis and a history of falling, spoke Taiwanese and also lacked a communication board. Staff acknowledged the absence of communication boards, which were required by the facility's policy.
The facility failed to implement safety measures for two residents. One resident, with epilepsy and a high fall risk, did not have floor mats or padded side rails as required by their care plan. Another resident, with impaired cognition, was found with cigarettes despite a policy requiring smoking materials to be kept at the nurse's station. Staff confirmed these oversights, which were against the facility's policies.
Three residents with indwelling catheters were not properly monitored for UTI symptoms, as required by the facility's P&P. One resident had a catheter with white sediments and cloudy urine, another had a kinked catheter tubing with sediments, and a third also had sediments in the catheter tubing. These deficiencies in monitoring and reporting could lead to delayed care and treatment.
The facility failed to properly manage gastrostomy tubes for two residents, leading to deficiencies in care. A resident's GT formula bottle was not labeled with the start time, and another resident did not receive the prescribed water flush. Observations and interviews confirmed these oversights, with staff acknowledging the importance of proper labeling and adherence to physician orders to prevent dehydration and tube clogging.
The facility failed to attempt alternatives to bed rails for two residents, risking entrapment and injury. One resident, with diabetes and anxiety, had bed rails up despite being able to get out of bed independently. Another resident, with dementia and COPD, had bed rails installed without documented attempts of alternatives, despite behavioral issues. The facility's policy requiring alternatives before bed rail use was not followed.
The facility failed to follow proper food sanitation and handling practices by placing raw meat next to ready-to-eat carrots in the refrigerator and storing used spoons with clean knives, risking contamination and foodborne illnesses.
A facility failed to provide Advance Directive (AD) information to a resident with dysphagia and dementia, as required by their policy. The resident's medical record lacked documentation of AD acknowledgment, and the Social Service Director confirmed that AD information was not offered to the resident or their representative.
Delayed Call Light and Toileting Response for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to promptly respond to resident call lights and toileting assistance requests for two residents. One resident, admitted with cellulitis of the right lower limb, type 2 diabetes mellitus, and dysphagia, had an MDS dated 3/20/2026 indicating no cognitive impairment and a need for supervision or touch assistance with bathing, lower body dressing, and footwear. In an interview on 4/22/2026 at 2:15 PM, this resident reported sometimes waiting a long time for staff to answer the call light, stating waits of about 30 minutes, particularly on weekends. Another resident, originally admitted with major depressive disorder, type 2 diabetes mellitus, hemiplegia, and hemiparesis, had an MDS indicating no acute change in mental status or cognitive pattern and total dependence on staff for toileting, lower body dressing, and putting on/taking off footwear. In an interview on 4/22/2026 at 12:55 PM, this resident reported delayed call light responses of approximately 30 minutes and stated that delays increased during the night, which was frustrating when the resident needed to be cleaned. The DON stated on 4/23/2026 at 12:35 PM that answering call lights promptly at all times was essential, especially for residents dependent on staff for care. The facility’s policies on Dignity and Respect and Call Light required residents to be treated with dignity and call lights to be answered within a reasonable time.
Failure to Ensure Timely Physician Notification for Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to promptly and effectively notify a resident’s physician of a significant change in condition involving fever and painful urination. The resident, who had diagnoses including pancytopenia, muscle weakness, and acute kidney failure, was cognitively intact and dependent on staff for several ADLs. On the evening prior to the surveyor’s interview, the resident developed a fever and reported burning pain with urination. The following morning, the resident reported still feeling febrile and continued burning with urination. Nursing documentation on an INTERACT Change in Condition Evaluation (CIC) form dated that evening recorded the fever and urinary burning and indicated that the physician had been notified and that staff were awaiting orders. Interviews with staff and review of text message records showed that the attending physician was never actually reached. An LVN reported texting the physician twice during the shift but receiving no reply, and acknowledged that the CIC entry stating the physician was notified was incorrect because there was no response. The DON provided screenshots confirming that text messages were sent to the physician at two times that evening with no response and confirmed that the physician was not notified of the change in condition. The DON and LVN both stated that staff should have contacted the Medical Director when the attending physician did not respond, as required by the facility’s Change in Condition policy, which states that the Medical Director shall be notified if the attending or on-call physician cannot be reached. A nurse practitioner working with the attending physician confirmed that neither the physician nor the nurse practitioner had been made aware of the resident’s fever and pain on that date.
Failure to Maintain Bed in Lowest Position and Supervise High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement an existing care plan intervention to prevent falls for one resident. The resident had diagnoses including type 2 diabetes mellitus, major depressive disorder, and a left femoral neck fracture, and was assessed on the MDS as dependent on staff for most ADLs, with no acute change in mental status or cognitive pattern. The resident’s care plan, initiated on a specified date, directed that the bed be kept in the lowest position to minimize risk of injury. A Change in Condition Evaluation documented that the resident was found sitting on the floor on the right side of the bed with their back against the wall. Subsequent observations on separate occasions showed the resident lying in bed with the bed not in the lowest position, and the bed frame not lowered close to the floor. During an interview conducted in the resident’s room, a CNA confirmed that the resident required supervision to sit up and lie in bed and to transfer in and out of bed or wheelchair, and acknowledged that the bed was not in the lowest position even though it should have been to reduce fall risk. The resident reported that they had fallen while attempting to transfer from the wheelchair back to bed because the wheelchair was too far from the bed, and stated that at the time of the fall the bed was not in the lowest position. The DON stated that the resident had been at high risk for falling, that staff should have supervised the resident, and that the bed must be in the lowest position with the call light within reach for safety, consistent with the facility’s Fall Management System policy, which requires an environment as free of accident hazards as possible and appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs.
Inaccurate Documentation of Physician Notification for Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident when documenting physician notification of a change in condition. The resident, who had diagnoses including pancytopenia, muscle weakness, and acute kidney failure, was cognitively intact and required varying levels of assistance with activities of daily living. On the evening in question, the resident experienced fever and burning pain with urination and reported having had a fever since the previous evening. A change in condition evaluation (CIC) dated 4/22/2026 documented that the resident had a fever and burning sensation on urination and that the physician was notified, with staff waiting for orders. Interviews and record review showed that the nurse responsible for the CIC, an LVN, had texted the resident’s physician twice using the facility cell phone but did not receive any reply. The LVN acknowledged that the CIC entry stating the physician was notified was incorrect because there was no response from the physician. The DON provided screenshots confirming that text messages were sent and that the physician did not respond, and confirmed that the facility’s method of verifying physician notification was receipt of a reply. The DON further confirmed that the physician was not actually notified of the resident’s change in condition on that date. This inaccurate documentation conflicted with the facility’s charting and documentation policy, which requires a complete account of the resident’s care, treatment, signs, and symptoms.
Delayed Call Light Response for Dependent Residents
Penalty
Summary
Nursing staff did not promptly respond to resident call lights, resulting in delays in assistance for multiple residents. One resident, admitted with a history of falling and muscle weakness, had an H&P indicating he could make his needs known but could not make medical decisions, and an MDS showing intact cognitive skills and a need for supervision to extensive assistance with ADLs. During an observation and interview in his room, he reported waiting approximately 25 minutes for assistance during the evening and night shifts. Another resident, admitted and later readmitted with paraplegia and muscle weakness, had an H&P indicating she had the mental capacity to understand and make medical decisions, and an MDS showing intact cognitive skills and a need for supervision to extensive assistance with ADLs. During an observation and interview in her room, the second resident reported that call light response times were a concern, particularly during night shifts, and that she experienced delays of approximately 15–20 minutes for assistance at night. She stated she was unable to walk, was incontinent of bowel and urine, and when soiled had to wait for someone to come and change her incontinence brief, which made her feel uncomfortable. Resident Council minutes documented that residents had reported call lights at night took longer to be answered. The DON stated that call lights were expected to be answered as soon as possible, that all staff members were able to answer call lights and assist residents, and that there should not be delays in response. The facility’s call light policy, revised in 1/2026, directed staff to answer call lights within a reasonable time.
Failure to Care Plan Transfer Assistance and Biliary Drain Management
Penalty
Summary
The facility failed to develop comprehensive care plans with measurable interventions for two residents. For the first resident, who had an above-the-knee left leg amputation and osteomyelitis of the right foot and ankle, the activities of daily living (ADL) care plan dated 1/5/2026 listed a goal to improve the current level of function in ADLs and an intervention to transfer the resident with staff participation, but did not specify that two-person assistance was required for transfers. The resident’s history and physical dated 1/8/2026 documented fluctuating capacity to understand and make decisions, and a Minimum Data Set (MDS) dated 2/25/2026 showed moderately impaired cognitive skills, need for varying levels of assistance with ADLs, and impairment of one lower extremity that interfered with daily function or placed the resident at risk of injury. Further record review for the first resident showed a physician progress note dated 3/11/2026 indicating a possible right 5th metatarsal head impaction fracture, with an expectation of healing in six months. A physical therapy (PT) evaluation and plan of treatment dated 3/13/2026 specified that the resident required maximum, two-person assistance with transfers. In interviews, a CNA stated the resident required maximum assistance for transfers from bed to wheelchair due to the left leg amputation and right foot fracture, and the Director of Physical Therapy confirmed the need for two-person assistance because of an unsteady gait, fluctuating mobility, and changing mental status. The DON acknowledged that the resident’s care plan should have indicated the need for two-person assistance during transfers. For the second resident, who was admitted with malignant neoplasms of the colon and axilla/upper limb lymph nodes, the history and physical dated 2/21/2026 documented intact decision-making capacity, and the MDS showed intact cognitive skills with varying levels of assistance required for ADLs. An order recap report dated 2/26/2026 documented an order to flush an abdominal biliary drain tube with 10 ml of sterile saline every day and evening shift. However, review of the electronic medical record revealed no care plan addressing the abdominal biliary drain tube. In interviews, the DON stated that care plans are developed to implement goals and interventions for residents’ health concerns and confirmed that the use of an abdominal biliary drain should have been included in the care plan with directions to monitor the drain, drainage amount, signs of infection, and changes in condition and pain. The facility’s policy on comprehensive person-centered care planning, dated 4/2025, required development of a comprehensive care plan with measurable objectives and timeframes to meet residents’ medical, nursing, mental, and psychosocial needs.
Unauthorized Room Search Violates Resident Privacy and Dignity
Penalty
Summary
Facility staff failed to honor a resident's right to privacy and dignity when the administrator searched the resident's room without the resident's consent. The resident, who had diabetes mellitus and heart failure, had an H&P indicating capacity to understand and make decisions, and an MDS showing independent cognitive skills for daily decision-making and independence in most ADLs. The resident reported that the administrator searched his room for cigarettes and lighters without informing him or obtaining his consent, and that staff should not walk into residents' rooms and search through their personal belongings without permission. The administrator stated that the resident was observed smoking on the patio and produced a lighter, and when staff asked the resident to surrender the lighter, the resident refused. The administrator reported that the police department was called, and the administrator and police entered the resident's room to search for a lighter without notifying the resident about the room search. The DON stated that facility staff could not search a resident's room without the resident's permission and that residents had the right to privacy. The facility's Resident Rights policy indicated that residents had the right to be treated with consideration, respect, and full recognition of their dignity and individuality.
Improper Storage and Retention of Discharged Resident’s Medication in Unsecured Area
Penalty
Summary
Surveyors identified a deficiency related to improper storage and handling of medications when a box of 5% lidocaine patches was found in an unsecured nursing supply shed. During observation, the medication box was seen on a shelf on top of diaper boxes in the shed, which was an area accessible to many people. The box was labeled with a resident’s name. The Director of Maintenance stated they had never seen the box before, did not know why it was there, and confirmed that medications should not be stored in the shed because many people had access to it. In a subsequent interview, the DON stated that medications are only supposed to be stored in medication carts and medication storage rooms, and confirmed that medications should not be stored in the shed, particularly since the box still had a resident’s name on it. The DON stated the medication belonged to a resident who had already been discharged from the facility and did not know why the medication was in the shed, suggesting that a staff member most likely grabbed the medication box and took it there. The DON characterized this as an unacceptable practice with a risk of medication diversion. Review of the facility’s 2023 Medication Storage policy showed that medications and biologicals are to be stored properly per manufacturer or supplier recommendations, accessible only to licensed nursing, pharmacy personnel, or staff lawfully authorized to administer medications, and that medications labeled for individual residents are to be stored separately from floor stock medications and not in the medication cart.
Failure to Complete and Update Smoking Evaluations per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its smoking policy and procedure for a resident who smoked. The resident had diagnoses including diabetes mellitus and heart failure and was documented in a recent H&P as having the capacity to understand and make decisions. An MDS assessment indicated the resident was independent in cognitive skills for daily decision making and independent in most ADLs, with supervision needed only for showering/bathing and footwear. The facility’s smoking evaluations for this resident, dated 11/13/2025 and 2/12/2026, were incomplete and did not document smoking frequency, smoking safety, whether the care plan was updated, or whether the resident received education on safe smoking practices, risks of smoking, or locations of designated smoking areas. A care plan for noncompliance with the smoking policy, dated 3/10/2026, only indicated that the intervention was to explain smoking P&P. Record review and staff interviews showed that the facility’s policy required all residents to be assessed to determine if it was safe for them to smoke, with results placed in the medical record, and that residents’ ability to smoke safely would be reassessed quarterly and whenever there was a change in cognition. The MDS nurse stated that smoking evaluations are to be completed quarterly, annually, or with a change in condition, that the form must be completely filled out to be valid, and that she had not completed the smoking evaluation for this resident. The DON confirmed that smoking evaluations are used to determine if it is safe for a resident to smoke, are to be completed quarterly and annually, and that all sections of the form must be completed or a reason documented if the resident refuses. The resident’s medical record did not contain a reassessment of smoking ability after a change of condition on 3/10/2026, and staff acknowledged that incomplete or untimely smoking evaluations could create smoking safety issues and that failure to complete the form could mean the resident was not informed of the smoking P&P.
Failure to Provide Ordered GT Hydration and Accurate MAR Documentation
Penalty
Summary
The facility failed to provide ordered hydration via gastrostomy tube (GT) for one resident, resulting in insufficient hydration. The resident had cerebral palsy, quadriplegia, dysphagia, severely impaired cognitive skills, and was dependent for all ADLs, and had a GT in place. A physician’s order dated 10/28/2025 directed that the resident receive 60 ml of water every hour for 20 hours per day via GT, totaling 1200 ml of water daily. On observation, there was no enteral feeding pump in the resident’s room to deliver the ordered hourly water. The Registered Dietician confirmed that the current hydration order was 60 ml of water every hour for 20 hours per day via GT. During interviews, LVN 1 stated they had never seen the physician’s order for hourly GT water and confirmed that such an order would normally be administered through a feeding pump, which had not been present in the resident’s room for a long time. The ADON acknowledged that the physician’s hydration order had been overlooked. LVN 2 also reported being unaware of the order and stated they had never seen a feeding pump in the resident’s room. Review of the MAR for the month showed that LVN 2 had documented administering 60 ml of water every hour on multiple dates and shifts, but LVN 2 stated that the resident did not actually receive water every hour and that the MAR entries were marked in error. The facility’s hydration policy required providing hydration based on the physician’s treatment plan and resident condition, which was not followed in this case.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report multiple allegations of abuse to the State Agency in accordance with its April 2025 policy on reporting alleged violations of abuse, neglect, exploitation, or mistreatment. The policy required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation is made, to the Administrator, State Survey Agency, and Adult Protective Services as appropriate. Despite this requirement, allegations involving three cognitively intact residents were not reported within the required timeframe. Resident 3, who had diagnoses including acute kidney failure, COPD, and UTI and was assessed as cognitively intact and independent in dressing, toileting, and personal hygiene, was the subject of an allegation that a CNA had spoken inappropriately about the size of the resident’s penis. This allegation was relayed to a CNA by another CNA but was not immediately reported to the DON or Administrator as required. Resident 4, who had acute kidney failure, type 2 diabetes mellitus, and muscle weakness, and required substantial/maximal assistance for bathing, lower body dressing, and toileting hygiene, was involved in a separate incident in which a CNA allegedly grabbed her own breasts in front of the resident and asked if they looked good. The CNA who witnessed this behavior considered it sexual harassment but did not report it promptly to leadership, instead waiting several days before informing an LVN, who then informed the Administrator. Resident 9, who had atrial fibrillation, muscle wasting and atrophy, and hypertensive chronic kidney disease, and required substantial/maximal assistance for bathing, lower body dressing, and toileting hygiene, reported that a CNA was aggressive, rude, told the resident to shut up, and argued with the resident. The resident reported this behavior to an LVN, who acknowledged receiving the allegation and stated that the LVN reported it to the Administrator in October 2025; however, the Administrator later stated being unaware of these allegations. The LVN also stated that neither the allegation involving Resident 4 nor the allegation involving Resident 9 was reported to the State Agency. The Administrator confirmed that an allegation involving inappropriate behavior toward a resident by a CNA was investigated internally and determined not to be abuse, and therefore was not reported to the State Agency, contrary to the facility’s policy requiring reporting of all alleged violations within the specified timeframes.
Failure to Implement Fall Management Interventions and Alarm Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Management System policy for two residents identified as being at risk for falls. For one resident with dementia, severe cognitive impairment, and a physician’s order to apply a bed pad alarm whenever the resident was in bed due to poor safety awareness, surveyors observed the resident sitting at the edge of the bed while the bed sensor pad alarm unit was hanging on the nightstand with the switch in the off position. The resident’s care plan also specified that a pad alarm was to be applied whenever the resident was in bed. During a concurrent observation and interview, the Infection Preventionist confirmed that the alarm was off and stated that the alarm needed to be on in order to sound when the resident attempted to get out of bed unassisted. For another resident with metabolic encephalopathy, Alzheimer’s disease, type 2 diabetes mellitus, severe cognitive impairment, and dependence or substantial/maximal assistance needs for multiple ADLs, the facility’s Interdisciplinary Team did not implement new interventions after the resident experienced multiple falls, including falls on two specific documented dates. Post-Event IDT Review forms for those falls did not show any new interventions, and the Director of Nursing confirmed that new interventions should have been implemented to prevent further falls. The Director of Nursing also confirmed that the resident’s care plan was not updated following the falls on those dates, despite the facility’s Fall Management System policy requiring investigation of falls, documentation of recommendations in the clinical record, and updating of the resident’s care plan.
Improper Labeling and Dating of Refrigerated Cheese Products
Penalty
Summary
Surveyors identified a deficiency in the facility’s food labeling and dating practices in the kitchen walk-in refrigerator, where multiple cheese products were not labeled in accordance with the facility’s policies and procedures. During an observation with the Dietary Supervisor, a plastic box of orange-colored shredded cheese was found labeled only with the date "12/30/25" and the word "cheese," without clarification of what the date represented (open, use by, or expiration) and without specifying the type of cheese. A plastic box of white, powdered cheese labeled as Parmesan was marked with the date "11/27/25" but again did not indicate whether this was an open date, use by date, or expiration date. Additionally, a plastic bag containing three blocks of orange-colored cheese was labeled with a delivered date of "12/24/25" and an opened date of "12/25/25" but lacked any use by or expiration date. In interviews, the Dietary Supervisor stated that foods in the kitchen should be labeled with a use by or expiration date to ensure expired foods are not used and that all expired food should be discarded immediately. The Dietary Aide similarly stated that it was important to label food with expiration and use by dates so staff would know when food could be used and that expired food should be discarded to prevent contamination. The Administrator stated that kitchen staff should ensure all food is labeled with a use by date to prevent using expired food. Review of the facility’s policies titled "Labeling and Dating of Foods" and "Refrigerated Storage Guide" showed that all food items in storage areas must be labeled and dated, that commercially processed ready-to-eat foods stored cold for more than 24 hours must be marked with a use by date, and that certain dairy and cheese products must be discarded by the manufacturer’s expiration date or within specified time frames after opening. The observed labeling practices for the cheese items did not comply with these written policies.
Failure to Repair Cracked Floor Creates Safety Hazard
Penalty
Summary
The facility failed to maintain the flooring in a safe and good repair, as evidenced by the presence of a cracked floor in the hallway from the entrance to nurse station 1, in front of the rehab service room and patio. Multiple residents, including those with mobility impairments and fall risks, were observed traversing this area. The cracked floor was directly observed by surveyors, and residents as well as staff acknowledged its unsafe condition, noting the potential for falls. Resident records reviewed showed that affected individuals had significant medical histories, including diabetes, COPD, osteoarthritis, cerebral infarction, hypertension, paraplegia, and rheumatoid arthritis. These residents required varying levels of assistance with mobility and activities of daily living, and their care plans specifically called for a safe, clutter-free environment to prevent falls. Despite these documented needs, the cracked floor remained unaddressed. Interviews with residents, a Licensed Vocational Nurse, the Maintenance Director, and the administrator confirmed that the cracked floor had not been reported or repaired. The Maintenance Log contained no entries regarding the issue, and no warning signs had been placed to alert residents or staff. The facility's own maintenance policy required regular upkeep of flooring to prevent injuries, but this was not followed in this instance.
Plan Of Correction
General Maintenance How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 10/09/25, the Maintenance Supervisor (MS) repaired the crack on the hallway floor near Station 1 and the Rehabilitation Room to eliminate any potential safety hazard for residents. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 10/21/25, the Safety Committee conducted a comprehensive walk through of the facility to identify any additional cracks or floor hazards throughout all resident and common areas. - No other residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 10/21/25 and 10/22/25, the Director of Staff Development (DSD) and Maintenance Supervisor (MS) provided in-service training to all staff regarding the use and importance of the Maintenance Log for timely reporting and follow-up on facility repairs. - Beginning 10/22/25, the Maintenance Supervisor will conduct floor inspections 2-3 times per week for three months to monitor for cracks or hazards and ensure prompt corrective action is taken as needed. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The Maintenance Supervisor (MS) will be reporting the results of the monitoring to the QA committee and safety committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy as prescribed for one patient with significant respiratory conditions. The patient, who had diagnoses including respiratory failure, COPD, pleural effusion, and was receiving palliative care, had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula or mask to maintain oxygen saturation above 90%. However, record reviews showed multiple instances where the patient was documented as being on room air instead of receiving continuous oxygen. Additionally, direct observations revealed the oxygen flow was set below the prescribed rate, at 1 to 1.5 liters per minute, rather than the ordered 2 liters per minute. Interviews with facility staff, including the ADON, LVN, IPN, and DON, confirmed that the physician's order for continuous oxygen was not followed. Staff acknowledged that the patient was not consistently provided with the ordered oxygen therapy and that the oxygen flow rate was not set as prescribed. The facility's policy and procedure on oxygen administration required adherence to physician orders, but this was not maintained in the care of this patient.
Plan Of Correction
Nursing Service--Administration of Medication How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, Patient 6's oxygen setting was corrected and adjusted to 2 L/min as ordered by the physician. - On 9/24/25, the Assistant Director of Nursing (ADON) provided a one-on-one in-service to LVN #2 regarding accurate oxygen administration in accordance with physician orders. - On 9/24/25, the ADON and Director of Staff Development (DSD) conducted an in-service for Licensed Nurses, CNAs, and staff on proper oxygen administration practices per physician orders and the facility's Oxygen Policy and Procedure. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 09/24/25, the Assistant Director of Nursing (ADON) conducted rounds on all residents receiving oxygen therapy to verify that oxygen settings were consistent with current physician orders. - No other residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - From 10/15/25-10/16/25, the ADON and DSD conducted in-service training for all Licensed Nurses, Certified Nursing Assistants (CNAs), and staff on accurate oxygen administration in accordance with physician orders and the facility's Policy and Procedure on Oxygen Use. - Starting 10/13/2025, the ADON and/or DSD will conduct random rounds 3x/week for 3 months to monitor compliance with proper oxygen administration per physician orders. Any findings identified during the rounds will be addressed promptly, and reeducation will be provided as necessary. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The ADON and/or DSD will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Call Light Not Accessible to High-Risk Resident
Penalty
Summary
The facility failed to ensure that a patient's call light was within reach, as required by both facility policy and the patient's care plan. During an observation, the call light for a patient with multiple medical conditions, including respiratory failure, COPD, pleural effusion, and a history of falls, was found under the patient's pillow and not accessible. The patient reported being unable to locate or reach the call light when needing to call for assistance. The patient's care plan specifically indicated that the call light should be within reach and that the patient should be encouraged to use it for assistance. Interviews with the Director of Nursing and a Licensed Vocational Nurse confirmed that the call light should always be accessible to patients to ensure their safety and timely care. Both staff members acknowledged that failure to provide access to the call light could delay care and increase the risk of falls. Review of facility policies further supported the requirement for call lights to be within reach before staff leave a patient's room. The deficiency was identified for a patient assessed as high risk for falls, with documented cognitive impairment and dependence on staff for several activities of daily living.
Plan Of Correction
C1115 Nursing Service--Patient Care How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, patients 6's call light was immediately placed within reach. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 9/24/25, the Director of Staff Development (DSD) conducted facility-wide rounds to verify proper placement of call lights. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 9/24/25, and 10/14/25, the DSD conducted in-service training for all staff on the proper use and placement of call lights, emphasizing the importance of ensuring that call lights are always within the resident's reach. - Starting 10/10/25, the DSD will conduct random checks of call light placement 5x/week reviewing 5 residents each day, for a duration of three months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The DSD will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Infection Control Policies and Procedures Not Accessible at Nurse's Stations
Penalty
Summary
The facility failed to ensure that infection control (IC) policies and procedures were available at all four nurse's stations as required. During observations and interviews, staff members at each nursing station, including an LVN, RN, Infection Preventionist Nurse (IPN), and Assistant Director of Nursing (ADON), were unable to locate the IC policy and procedure binder in their respective stations. The IPN confirmed that the IC policies and procedures were kept inside the IPN's office rather than being accessible at each nursing station. Staff reported that, in the absence of the binder, they would consult the Director of Nursing (DON) for guidance on infection control matters. The DON acknowledged that the facility's IC policies and procedures should be present at all nursing stations to provide staff with immediate access to guidelines for proper care and treatment, especially during an outbreak or infection control issue. The lack of readily available IC policies and procedures at the nurse's stations had the potential to deprive nursing staff of important information necessary for infection control practices.
Plan Of Correction
C1280 Nursing Service--Patients with Infectious Dis How corrective action will be accomplished for those residents found to have been affected by the identified practice: Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, copies of the current Facility Infection Control Policies and Procedures Manual were printed and placed at all four nursing stations by the Infection Preventionist. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 9/24/25, the Infection Preventionist (IP) verified that all four nursing stations contained the Infection Control Policies and Procedures Manual. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 9/24/25 and 10/10/25, the Infection Preventionist (IP) conducted an in-service training to educate staff on the location and accessibility of the facility's Infection Control Policies and Procedures Manual. - Starting 10/14/25, the Infection Preventionist will monitor the availability of the Infection Control Policies and Procedures manual at each nursing station 2x/week for three months to ensure accessibility for all staff. How the facility plans to monitor its performance to make sure that solutions are sustained: - The plan must be implemented, and the corrective action evaluated for its effectiveness. - The POC is integrated into the quality assurance system. - The Infection Preventionist will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Missing Local Health Officer Contact Information at Nursing Stations
Penalty
Summary
The facility failed to ensure that the name, address, and telephone number of local health officers were available in all four nursing stations, as required. During observations and interviews, staff members at Nursing Stations 1, 2, 3, and 4, including a registered nurse, the infection prevention nurse, and the assistant director of nursing, were unable to locate this information at their respective stations. The director of nursing confirmed that this contact information was not present in any of the nursing stations, which is necessary for staff to easily access local health officer contact details for guidance.
Plan Of Correction
C1285 Nursing Service--Patients with Infectious Dis How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, the Administrator Assistant posted updated information for the current Local Health Officers at all four nursing stations. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken. - On 9/24/25, the Administrator Assistant verified that all four nursing stations had the current Local Health Officers information posted. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur. - On 9/24/25 and 10/10/25, the Administrator Assistant conducted an in-service training to educate staff on the location and accessibility of the Local Health Officers' information. - Starting 10/14/25, the Administrator Assistant will monitor the posting of the Local Health Officers' information at each nursing station 2x/week for three months to ensure accessibility for all staff. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The Administrator Assistant will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Incorrect Insulin Storage Labeling and Unsigned Physician Order Recaps
Penalty
Summary
The facility failed to ensure accurate storage instructions on medication labels for insulin injection pens belonging to three patients with type 2 diabetes mellitus. During an observation of the medication cart, it was found that the labels on one Novolog and two Lantus Solostar insulin pens incorrectly instructed staff to keep the pens refrigerated after opening. Licensed staff acknowledged that insulin does not require refrigeration after opening and that the labeling should have been clarified with the pharmacist. The facility's policy required proper and safe storage of drugs, including correct labeling, but this was not followed for these medications. Additionally, the facility failed to ensure that monthly physician's order recapitulation reports were signed and dated for two patients. This omission was identified through interview and record review, and it was noted that the lack of proper documentation had the potential to result in patients not receiving accurate medication and treatment as ordered. The facility's policy required that physician orders be correctly recapitulated, signed, and dated, but this was not done for the affected patients.
Plan Of Correction
Pharmaceutical Service--General How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/25/25, the Novolog 100 U/ml and two Lantus Solostar 100 injection pens for patients 10, 11, and 12 were immediately discarded. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - All residents with insulin orders are considered at risk of being affected. - On 10/10/25, the Director of Nursing (DON) conducted an audit of all residents with insulin orders to identify any instances of improper insulin storage. - Following the audit, it was determined that no other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 9/26/25, the Director of Nursing (DON) conducted an in-service with LVN#1 regarding accurate medication storage practices. - The education included a detailed review of the medication labeling instructions, with an emphasis on the proper storage requirements for insulin to maintain potency and efficacy. - On 10/10/25 and 10/16/25, the Director of Nursing (DON) conducted in-service training for all licensed nurses on the facility's policy and procedure for accurate medication storage practices. - The education included a detailed review of the medication labeling instructions, with particular emphasis on the proper storage requirements for insulin to maintain potency and efficacy. - Starting 10/16/25, the DON and/or ADON will conduct random audits 2-3 times per week for 3 months to ensure proper insulin storage. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The DON and/or ADON will be reporting the results of the monitoring to the QA committee monthly for 3 months for review and recommendations and to ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and develop an action plan to prevent any further deficient practices. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - All residents with insulin orders are considered at risk. - On 10/10/25, the Director of Nursing (DON) conducted an audit of all residents with insulin orders to identify any instances of improper insulin storage. - Following the audit, it was determined that no other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 9/26/25, the Director of Nursing (DON) conducted an in-service with LVN#1 regarding accurate medication storage practices. - The education included a detailed review of the medication labeling instructions, with an emphasis on the proper storage requirements for insulin to maintain potency and efficacy. - On 10/10/25 and 10/16/25, the Director of Nursing (DON) conducted in-service training for all licensed nurses on the facility's policy and procedure for accurate medication storage practices. - The education included a detailed review of the medication labeling instructions, with particular emphasis on the proper storage requirements for insulin to maintain potency and efficacy. - Starting 10/16/25, the DON and/or ADON will conduct random audits 2-3 times per week for 3 months to ensure proper insulin storage. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The DON and/or ADON will be reporting the results of the monitoring to the QA committee monthly for 3 months for review and recommendations and to ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and develop an action plan to prevent any further deficient practices. Content of Health Records How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 09/24/25, the monthly Physician's Order Recapitulation Reports for Patients #7 and #8 were reviewed, signed, and dated by the physician. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 9/26/25, the Medical Records Director conducted a facility-wide audit to verify all Physician's Order Recapitulation Reports were named, signed, and dated. - No other residents were affected by this finding.
Physician Order Recapitulation Reports Not Properly Signed and Dated
Penalty
Summary
The facility failed to ensure that monthly physician order recapitulation reports were properly signed and dated for two patients. For one patient, the Order Summary Reports (OSRs) for two consecutive months did not include the name of the physician who approved the orders, the physician's signature, or the date of approval. During a review with the Director of Nursing (DON), it was confirmed that the monthly recapitulated orders were either unsigned, missing the physician's name, or undated, and the DON acknowledged that the OSRs needed to be signed and dated by the approving physician each month. For the second patient, similar deficiencies were found. The OSRs for two months did not indicate the name of the physician who approved the orders or the date of approval. The DON confirmed during an interview that the monthly physician's recapitulated orders for these months did not include the approving physician's name or the date of approval. Both patients had significant medical conditions, including diabetes mellitus type 2 and cognitive impairments, with one requiring maximum assistance for daily activities and the other being dependent on staff for all care needs. The facility's policy required that monthly recaps be noted by a licensed nurse when the physician signs the recapitulation of orders, but this was not followed in these cases.
Plan Of Correction
Content of Health Records How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 09/24/25, the monthly Physician's Order Recapitulation Reports for Patients #7 and #8 were reviewed, signed, and dated by the physician. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 9/26/25, the Medical Records Director conducted a facility-wide audit to verify all Physician's Order Recapitulation Reports were named, signed, and dated. - No other residents were affected by this finding. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 10/10/2025, the Director of Nursing (DON) provided an in-service to the Medical Records staff regarding proper completion of the Physician's Order Recapitulation Reports, with emphasis on ensuring all reports are accurately identified, signed, and dated by the physician. - Starting 10/10/25, the Medical Records Director will audit all Physician's Order Recapitulation Reports once a week for 3 months to ensure all reports are accurately identified, signed, and dated by the physician. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The Medical Records Director will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 10/10/2025, the Director of Nursing (DON) provided an in-service to the Medical Records staff regarding proper completion of the Physician's Order Recapitulation Reports, with emphasis on ensuring all reports are accurately identified, signed, and dated by the physician. - Starting 10/10/25, the Medical Records Director will audit all Physician's Order Recapitulation Reports once a week for 3 months to ensure all reports are accurately identified, signed, and dated by the physician. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The Medical Records Director will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Failure to Document Medication and IV Therapy Administration as Ordered
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two patients by not following physician orders and facility policy regarding medication and treatment administration records. For one patient with diagnoses including diabetes mellitus type 2 and chronic pain syndrome, the order summary required monitoring and documentation of episodes of depression, specifically unconsolable crying, while on Zoloft. However, the Medication Administration Record (MAR) for September 2025 showed that this monitoring was not documented, checked, or signed off as performed on multiple dates and shifts. The Director of Nursing confirmed that the required documentation was missing for these periods and acknowledged that such monitoring was necessary to determine the effectiveness of the medication. For another patient with dementia and protein-calorie malnutrition, the order summary required administration of Dextrose Sodium Chloride (D5NaCl) Solution 5-0.45% at a specified rate until the patient consumed more than 50% of food intake. The Intravenous Medication Administration Record (IV MAR) indicated that the administration and documentation of this IV therapy were not completed or signed off on three specific dates. The Director of Nursing confirmed the lack of documentation and stated that the fluids were not documented as administered as ordered. The facility's policies and procedures required adequate monitoring and documentation for both medication and IV therapy, including specifying the type of fluid, rate of infusion, and the signature and title of the person recording the data. The failures in documentation for both patients resulted in incomplete medical records, as confirmed by record review and staff interviews.
Plan Of Correction
Content of Health Records How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/25/25, Patient 7 was reassessed following a reported episode of inconsolable crying possibly related to the current antidepressant medication. Upon assessment by the RN Supervisor, no further episodes of inconsolable crying were observed. The physician was notified and reviewed the resident's current medications and behavioral patterns for a 3-month look-back period. Gradual Dose Reduction (GDR) was initiated. - On 09/29/2025, a 1:1 in-service training was conducted with the RN responsible for Patient 9's IV therapy regarding accurate documentation practices, including type of IV fluid, rate of infusion per hour, additives, if and signature and title of the person recording the data. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - All residents with antidepressant medication are potentially at risk of being affected. - All residents with IV Hydration, IV medication, and Peripheral Lines are potentially at risk of being affected. - On 10/10/25, the Director of Nursing (DON) conducted a comprehensive audit of all residents with an order for antidepressant medication to ensure accuracy and completeness of behavior monitoring documentation. - No other residents were affected by this deficient practice. - On 10/10/25, the Director of Nursing (DON) conducted an audit of all residents with an order for IV Hydration, IV medication, and peripheral lines. The audit emphasized accurate documentation practices, including identification of IV fluid type, infusion rate (mL/hour), additives if applicable, and the signature name and title of recording nurse. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - From 10/10/25 to 10/16/25, the Director of Nursing (DON) conducted in-service training for licensed nurses on the facility's medication administration policy and procedure, emphasizing the importance of accuracy and completeness of behavior monitoring documentation. - From 10/10/2025 to 10/16/2025, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) conducted in-service training for licensed nurses regarding the facility's medication administration policy and procedure, emphasizing accurate documentation practices, including identification of IV fluid type, infusion rate (mL/hour), additives if applicable, and the signature name and title of recording nurse. - Starting 10/16/25, the DON and/or ADON will conduct a random audit 2-3 times per week for 3 months of residents with an order for antidepressant medication to ensure accuracy and completeness of behavior monitoring documentation. - Starting 10/16/25, the DON and/or ADON will conduct a random audit 2-3 times per week for 3 months of residents with IV Hydration, IV medication, and residents with peripheral lines. The audit will emphasize accurate documentation practices, including identification of IV fluid type, infusion rate (mL/hour), additives if applicable, and the signature name and title of the recording nurse. - Any findings identified during the audits will be addressed promptly, and reeducation will be provided as necessary. A summary of each audit will be submitted to the DON and ED for review and follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: - The DON and/or ADON will report the results of the monitoring to the QA committee monthly for 3 months for review and recommendations, ensuring substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root causes and develop an action plan to prevent any further deficient practices.
Failure to Provide Required Patient Identification Wristbands
Penalty
Summary
The facility failed to provide wristband identification tags or any other means of identification for two of three sampled patients, as required by regulation and the facility's own policy. Patient 7, who was admitted with diagnoses including diabetes mellitus type 2 and chronic pain syndrome, was found during observation to have no wristband or other identification while lying in bed. Patient 7's Minimum Data Set (MDS) indicated moderately impaired cognition and a need for maximum assistance with several activities of daily living. Both the patient and the Director of Staff and Development (DSD) confirmed the absence of an identification wristband, with the DSD acknowledging the necessity of such identification, especially during medication administration and emergencies. Patient 8, admitted with diabetes mellitus type 2 and cognitive impairment, was also observed without a wristband or any other form of identification. The MDS for Patient 8 showed severely impaired cognition and total dependence on staff for all activities of daily living. The DSD confirmed that Patient 8 did not have any identification wristband or alternative means of identification. The Director of Nursing (DON) further stated that all patients, particularly those who are nonverbal or confused, should have wristband identification at all times to ensure proper identification before care and treatment. A review of the facility's policy and procedure titled "Admission, Discharge and Transfer" indicated that wristbands or ankle bands must be worn by residents at all times to ensure proper identification prior to receiving medication, treatment, or special services. Despite this policy, the observations and interviews confirmed that both Patient 7 and Patient 8 were not provided with the required identification, constituting a failure to meet the licensure requirement.
Plan Of Correction
Patient Identification How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, patients 7 and 8 were immediately provided with wristbands after it was identified that they were without one. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken. - All residents are at risk of being affected. - On 9/26/25, a facility-wide resident identification wristband audit was conducted by the Administrator Assistant. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur. - On 9/24/25, the Admissions Department received in-service training on the proper placement of identification wristbands for all admitted residents, conducted by the Administrator Assistant. - From 10/13/25-10/15/25, all staff received in-service training on resident identification wristbands, conducted by the Administrator Assistant. - Starting 10/13/25, the Administrator Assistant will perform random weekly checks of five residents for 3 months using an audit form to ensure proper use of identification wristbands. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The Administrator Assistant will be reporting the results of the monitoring to the QA committee monthly for 3 months for review and recommendations and to ensure substantial compliance is sustained. Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Failure to Follow Physician Orders and Document Insulin Administration
Penalty
Summary
The facility failed to provide necessary care and services to a resident with type 2 diabetes mellitus by not following physician's orders for medication administration and by failing to accurately document medication administration. Specifically, a Licensed Vocational Nurse (LVN) held multiple doses of Tresiba, a once-daily insulin medication, without a physician's order to do so. The nurse based the decision to hold the medication on the resident's blood sugar level, despite the absence of any such instruction in the physician's order. The nurse notified the Registered Nurse Supervisor about holding the medication, but the physician was not informed, and the facility's policy required a doctor's order before holding any medication not specified in the original order. Additionally, there was a failure in documentation when another LVN administered Tresiba to the same resident but did not record the administration in the Medication Administration Record (MAR) as required by facility policy. The resident confirmed receiving the medication, and the nurse also stated it was given, but the MAR did not reflect this. The facility's policy mandates that medication administration be documented immediately after administration, which was not followed in this instance.
Plan Of Correction
F0684 Quality of Care How corrective action will be accomplished for those residents found to have been affected by the identified practice: • On 8/9/25, Resident 1 was transferred to the hospital for further evaluation. • On 09/08/2025, 1:1 Inservice with LVN 1 regarding obtaining physicians' orders prior to holding medication. • On 09/08/2025, 1:1 Inservice with LVN 2 regarding accurate medication administration documentation. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: • All residents in the facility with long-acting insulin are potentially at risk of being affected. • On 09/08/2025, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) conducted an audit of all residents with orders for long-acting insulin to identify any instances of medication being withheld without a physician's order. • No other residents are affected by this deficient practice. On 09/08/2025, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) audited all medication administration records to ensure accurate documentation for residents with long-acting insulin orders: • No other residents are affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: • From 09/09/2025 to 09/12/2025, the Director of Nursing (DON) conducted in-service training for licensed nurses on the facility's medication administration policy and procedure, emphasizing the importance of obtaining a physician's order before withholding any medication. • From 09/09/2025 to 09/12/2025, the Director of Nursing (DON) conducted in-service training on accurate documentation practices for medication administration to ensure compliance with facility standards. • Starting on 09/10/2025, the DON and ADON will conduct random 3-5 times a week audits for any long-acting insulin withheld without a physician's order. • Starting 09/10/2025, the DON and ADON will conduct random 3-5 times a week audits for accurate documentation of all medication administration for all residents with long-acting insulin orders. • Any findings identified during the audits will be addressed promptly, and reeducation will be provided as necessary. A summary of each audit will be submitted to the DON and ED for review and follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: • The DON and ADON will be reporting the results of the monitoring to the QA committee monthly for three months for review and recommendations and to ensure substantial compliance is sustained. • Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Failure to Secure Smoking Materials and Provide Supervision for Residents Who Smoke
Penalty
Summary
Multiple residents with a history of smoking were found to have unsupervised access to cigarettes and lighters, contrary to the facility’s smoking policy and individualized care plans. One resident, with diagnoses including anxiety and bipolar disorder, was observed to keep cigarettes and a lighter in their possession, despite documentation indicating the need for supervised smoking and that all smoking materials should be stored securely by staff. Staff members, including a CNA, LVN, AD, DON, and ADM, were unaware that this resident had these items, and the resident reported obtaining them from a family member during visitation. The facility’s policy required all smoking materials to be locked at the nurse’s station, but this was not followed. Another resident, with heart failure and a pacemaker, also kept cigarettes and a lighter at their bedside and smoked on the patio without supervision. The care plan and smoking evaluation for this resident specified the need for supervised smoking and secure storage of smoking materials. The DON and ADM were not aware that the resident had these items, and the items were only retrieved after the issue was discovered. The facility’s policy, as stated by the DON, did not allow residents to keep smoking materials in their possession due to fire risk. A third resident, with anxiety disorder, palliative care needs, and severely impaired cognition, was found to have a lighter and cigarettes in their pocket. This resident was able to access the smoking patio independently by using a pin code, which staff stated should only be known by designated personnel to ensure supervision. Staff interviews confirmed that the resident could go to the patio and smoke unsupervised, in violation of the care plan and facility policy. The facility’s written policy required all smoking materials to be retained by nursing staff and for residents to be supervised while smoking, but these procedures were not consistently implemented.
Failure to Ensure Resident Dignity, Privacy, and Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure the dignity, privacy, and respect of four residents during the provision of care, as evidenced by multiple observed incidents. In one case, the Director of Staff and Development (DSD) checked a resident's gastrostomy tube site without closing the privacy curtain, exposing the resident's abdominal area to the roommate and hallway. Both the DSD and the Director of Nursing (DON) acknowledged that privacy curtains should be closed to maintain resident dignity during care, and facility policy confirmed this requirement. Another incident involved a resident with bilateral nephrostomy bags, where the drainage bags were left uncovered and visible, exposing the contents to view. The DSD and DON confirmed that the facility's policy required the use of privacy covers for such devices to maintain resident dignity. The DON stated that this policy applied to all body fluid collection devices, including nephrostomy bags, and that the lack of a privacy cover was not in accordance with facility procedures. Additional deficiencies were observed when two nursing assistants provided care to a resident without being able to fully close the privacy curtain due to missing hooks, resulting in potential exposure when the door was opened. Furthermore, another resident was not offered the opportunity to use the bathroom for several hours and was left sitting in a urine-soaked brief, despite being able to communicate the need for toileting assistance. Staff interviews confirmed that the resident was not always incontinent and could request help, but was not consistently offered the chance to use the restroom, contrary to the resident's care plan and facility policy.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which could impact the care planning process and the delivery of appropriate services to residents. Specific details about the residents involved or the nature of the inaccuracies in the assessments are not provided in the report.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents with specific medical needs, as identified through observation, interviews, and record reviews. For one resident with anxiety disorder and insomnia, there was no care plan initiated or implemented for the use of Buspirone, despite physician orders and staff acknowledgment that such a plan was necessary to ensure proper and effective interventions. The facility's own policy required a comprehensive, person-centered care plan to be developed within seven days of the Minimum Data Set (MDS) assessment, but this was not done. Another resident with diagnoses including enterocolitis due to Clostridium difficile and irritable bowel syndrome experienced severe abdominal pain, but no care plan was developed to address this symptom. The resident repeatedly reported pain, and pain medication was administered, but documentation did not consistently indicate the location of the pain. The care plan for pain did not address abdominal pain specifically, nor did the care plan for Clostridium difficile include monitoring for abdominal symptoms, contrary to CDC recommendations. A third resident with a history of recurrent urinary tract infections (UTIs) and multiple hospitalizations for UTIs did not have a comprehensive care plan addressing this issue. The only care plan found was a short-term plan following hospitalizations, which did not include interventions to prevent further UTIs. Additionally, a fourth resident receiving Hydrocodone-Acetaminophen for pain management did not have a care plan in place to address the use of this opioid medication, despite its black box warning and the need for monitoring for adverse effects. In each case, staff interviews confirmed the absence of appropriate care plans and acknowledged the importance of such plans for guiding care and monitoring resident conditions.
Milk Not Maintained at Safe Temperature During Meal Service
Penalty
Summary
The facility failed to ensure that 20 cups of milk, including thickened and boxed milk, were maintained at or below the required temperature of 41 degrees Fahrenheit during meal service. During a kitchen observation, the milk was found placed on top of plastic trays at room temperature, with measured temperatures of 57°F for thickened milk and 47.8°F for boxed milk. The milk had been removed from the chiller at 7:00 AM and left out on trays as the meal service began, without being placed on ice. The kitchen staff reported that milk was not placed on ice during breakfast because the kitchen was perceived as not being as hot during that time, despite the kitchen temperature being recorded at 81.5°F during the observation. A review of the facility's policy and procedure indicated that cold foods should be kept in the refrigerator or freezer and only pulled out in small quantities as close to serving time as possible to ensure temperatures remain below 41°F. The policy also required periodic monitoring of food temperatures throughout meal service. The observed practice of leaving milk out at room temperature and not monitoring or maintaining the required cold holding temperature was inconsistent with the facility's established procedures.
Failure to Implement Infection Prevention and Control Policies
Penalty
Summary
The facility failed to implement its infection prevention and control policies and procedures for five sampled residents, resulting in multiple deficiencies. For one resident with dementia and osteoarthritis, the urinal was found hanging on a garbage can, unlabeled and filled with urine, rather than being labeled and stored in a designated basket as required. Staff interviews confirmed that urinals should be labeled with the resident's name or room number and stored properly to prevent cross-contamination, but this was not done in this instance. Another resident with end stage renal disease and a dialysis catheter, who was on Enhanced Barrier Precautions (EBP), did not have staff wearing the required personal protective equipment (PPE) during high-contact care activities such as range of motion exercises. The staff member acknowledged that gowns and gloves should have been worn to prevent cross-contamination, and facility policy confirmed this requirement for residents with indwelling medical devices or a history of multidrug-resistant organisms (MDROs). Additionally, a staff member failed to change PPE between providing care to two different residents, both of whom were on EBP due to wounds or indwelling devices. The staff member wore the same gown and gloves while assisting both residents with personal care and did not perform hand hygiene or don new PPE between residents, contrary to facility policy and staff training. In another case, a resident with bilateral nephrostomy tubes did not have EBP signage or a PPE cart outside the room, and staff were unaware of the need for EBP, resulting in care being provided without the required gown and gloves. These failures were observed and confirmed through staff interviews and review of facility policies.
Failure to Maintain Safe and Homelike Resident Room Environment
Penalty
Summary
A deficiency was identified when a resident's bedroom wall was found to be missing part of the baseboard, exposing drywall and peeling paint. This condition was observed during a survey in the resident's room, specifically behind the bed. The resident had a history of sepsis, lack of coordination, and dysphagia, and was assessed as having moderately impaired cognition. The resident used a walker and required setup or clean-up assistance with toileting hygiene. The missing baseboard and exposed wall were confirmed by both the Director of Nursing (DON) and the Maintenance Supervisor (MS) during interviews and observations, with both acknowledging that the area should not be left in that condition. The facility's policies and procedures for housekeeping and maintenance were reviewed and indicated that the environment should be kept clean, comfortable, homelike, and sanitary, and that the building and equipment should remain safe, clean, and functional for residents, staff, and visitors. The failure to maintain the resident's room in accordance with these policies resulted in a living area that was not safe, clean, or homelike, as required.
Failure to Notify Physician and Document Change of Condition for Resident with No Bowel Movement
Penalty
Summary
The facility failed to ensure that a change in condition was identified and that the physician was notified for a resident who had not had a bowel movement for four days. The resident, who had diagnoses including enterocolitis due to clostridium difficile and irritable bowel syndrome, was dependent on staff for toileting and mobility. Documentation showed no bowel movement for several consecutive days, and the resident reported severe abdominal pain rated at 10/10. Despite a clinical alert for no bowel movement being generated, there was no evidence in the records that a change of condition was documented or that the physician was notified during this period. Interviews with nursing staff revealed gaps in communication and follow-through regarding the resident's condition. The Assistant Director of Nursing acknowledged that the absence of a bowel movement for more than three days should have triggered a change of condition and physician notification, as per facility policy. However, neither the required assessment nor the notification occurred. Licensed nursing staff indicated reliance on hand-off communication and did not receive or act upon alerts or reports from certified nursing assistants regarding the resident's status.
Failure to Obtain Physician Order and Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain a physician order and informed consent prior to the installation of bilateral upper side rails for a resident. The resident, who was admitted with hemiplegia, hemiparesis, and dysarthria, was observed lying in bed with both upper side rails raised. The resident was noted to have right-sided paralysis and was dependent on staff for several activities of daily living. During interviews and record reviews, it was confirmed by the DON that there was no documentation in the resident's chart or electronic medical record indicating that a physician order or informed consent had been obtained before the side rails were installed. The facility's policy required that alternatives to bed rails be attempted and, if unsuccessful, that the interdisciplinary team assess the resident for risk of entrapment, review risks and benefits, and obtain informed consent prior to bed rail use. Despite these requirements, the necessary documentation and consent process were not completed for this resident, as confirmed by both observation and staff interviews.
Failure to Provide Ordered Plate Guard During Meals
Penalty
Summary
A resident with diagnoses including hemiplegia, hemiparesis, dysarthria, and adult failure to thrive was admitted to the facility and had a physician's order to use a plate guard during all meals. The resident's Minimum Data Set indicated intact cognition but dependence on staff for several activities of daily living. Despite the order, during an observation at mealtime, the resident was found eating without a plate guard, resulting in food spilling onto their blanket and clothes. The resident was observed picking up spilled food from their blanket and clothes while eating with their left hand. Interviews with a Licensed Vocational Nurse and the Director of Nursing confirmed that the resident should have been provided with a plate guard as ordered, to assist with scooping food and to prevent spillage. Review of the facility's policy indicated that residents recommended to use a plate guard should have it available and in place during meals. The failure to provide the ordered adaptive equipment constituted a deficiency in care.
Failure to Ensure Functioning Bed and Wheelchair Alarms
Penalty
Summary
The facility failed to ensure that essential equipment, specifically bed and wheelchair alarms, were functioning properly for a resident with diagnoses including Parkinson's disease, encephalopathy, and abnormal gait and mobility. The resident required moderate assistance with mobility and had orders for sensor pads in both bed and wheelchair to alert staff when attempting to get up unassisted. During observation, the bed alarm functioned as expected, but the wheelchair alarm did not sound when the resident was assisted to stand. The Assistant Director of Nursing attempted to fix the pad and switch alarms, and only after switching to a different alarm did the device function correctly. Interviews with facility leadership revealed there was no monitoring system in place to check the functionality of bed and wheelchair alarms, and no policy or procedure regarding the use of tab alarms. Review of facility policies indicated a general requirement to maintain equipment in good working order, but there was no specific guidance or monitoring process for the alarms in question. This lack of oversight and procedure led to the failure to ensure the resident's safety equipment was consistently operational.
Nurse Staffing Information Not Posted in Prominent, Accessible Location
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent place that was readily accessible to residents and visitors. Observations on multiple days revealed that the staffing sheet was only posted on the consumer board in a hallway, with no postings at the facility entrance or at any of the nursing stations. During interviews, the Director of Staff Development (DSD) confirmed that she was responsible for the nurse staffing postings and acknowledged that the information was only displayed on the consumer board in the hallway. The DSD also stated that the facility was large and that some residents, particularly those using wheelchairs, could not view the posting. Review of the facility's Shift Hours Form indicated that nurse staffing information was supposed to be posted daily in a prominent place at the beginning of each shift and be accessible to residents and visitors.
Failure to Report and Assess Resident Injury Following Transfer Incident
Penalty
Summary
The facility failed to follow its policy and procedure regarding significant changes of condition for a resident with a history of hemiplegia, hemiparesis, diabetes, and muscle atrophy. During a morning shift, a Certified Nursing Assistant (CNA) transferred the resident from a shower chair to bed, during which the resident's left leg, which was paralyzed, became caught on the shower chair. The CNA did not report this incident to a charge nurse or supervisor, stating that the resident did not complain of pain at the time. However, another CNA later heard the resident complain of left foot pain and informed a Registered Nurse (RN), who administered Tylenol and documented its effectiveness, but did not further assess or document the incident involving the leg. Later that day, the resident complained of pelvic and left knee pain, and bruising was observed on the left lateral leg. The physician was notified, and an x-ray was ordered, which revealed a depressed lateral tibial plateau fracture. Interviews with facility leadership confirmed that the incident should have been reported and assessed as a significant change of condition, with appropriate documentation and physician notification. The facility's policy requires that any change in a resident's condition, such as a decline in physical function or an incident, be reported to a licensed nurse or supervisor, who must then assess, document, and communicate with the provider as needed. In this case, the failure to report and assess the incident involving the resident's leg delayed necessary care and services, as the injury was not promptly identified or addressed according to policy.
Incomplete Documentation of Resident Injury
Penalty
Summary
The facility failed to follow its own policy and procedure regarding charting and documentation by not providing complete documentation for a resident who was found with purplish discoloration on the right great toe. The resident, who had a history of chronic obstructive pulmonary disease, acute kidney failure, and chronic systolic heart failure, was dependent on staff for several activities of daily living, including toileting, bathing, dressing, and footwear. The eINTERACT Change in Condition Evaluation noted the discoloration but did not document how the injury occurred. Progress notes for the relevant month also lacked any explanation for the discoloration. Interviews with staff revealed that the resident had struck their right foot during a shower, either by hitting something unknown or by kicking a doorway while attempting to kick a CNA. Both the LVN and RN interviewed acknowledged that details of the incident should have been documented, and the DON emphasized the importance of complete documentation to understand what happened and to prevent recurrence. The facility's policy required concise and continuous documentation of treatment, care, and changes in resident condition, but this was not followed in this case.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to promptly notify the physician of a change in condition for a resident who experienced increased swelling in the left leg and foot. The Licensed Vocational Nurse (LVN) observed the swelling on multiple occasions but did not complete a Change of Condition (COC) form or notify the resident's physician as required by the facility's policy. This delay in communication resulted in a lack of timely medical intervention for the resident's condition. The resident, who had a history of type 2 diabetes mellitus with diabetic neuropathy and chronic kidney disease, was admitted with existing venous and arterial ulcers. Despite the resident's complex medical history and the presence of severe pitting edema, the LVN only visually monitored the condition without notifying the physician or completing the necessary documentation. The swelling was noted to be an indication of circulation problems, which could lead to complications such as ulcers and wounds. The Director of Nursing (DON) confirmed that the facility's policy required licensed nurses to notify the physician and monitor the condition for 72 hours if a change in condition was observed. The DON acknowledged that the failure to notify the physician in a timely manner put the resident at risk for further skin breakdown and complications. The facility's policy emphasized the importance of prompt communication and documentation to ensure residents receive appropriate care and treatment.
Failure to Document and Address Change of Condition
Penalty
Summary
The facility failed to monitor and document a change of condition for a resident, identified as Resident 8, as per the facility's policy and procedure on Significant Change of Condition. The Licensed Vocational Nurse (LVN) 3 did not complete a Situation-Background-Assessment-Recommendation (SBAR) or Change of Condition (COC) form when an increase in swelling was observed in Resident 8's left leg and foot. This oversight occurred on two occasions, first when the swelling was initially noted and again when the condition did not improve after 72 hours. Resident 8, who had a medical history including type 2 diabetes mellitus with diabetic neuropathy and chronic kidney disease, was admitted with existing venous and arterial ulcers. The resident required assistance with daily activities and used a wheelchair. Despite the care plan interventions that required monitoring and reporting of signs of infection or changes in condition, LVN 3 only visually monitored the swelling without completing the necessary documentation or notifying the physician. This lack of action potentially delayed the care and treatment needed for Resident 8's condition. The Director of Nursing (DON) confirmed that the facility's protocol required licensed nurses to notify the physician and complete a COC form when a resident's condition changed. The DON acknowledged that the failure to notify the physician and complete the necessary documentation could have contributed to the worsening of Resident 8's condition, including the development and deterioration of toe wounds. The facility's policy emphasized the importance of timely assessment and intervention to maintain residents' well-being.
Improper Application of Ointments by CNA Without Physician's Order
Penalty
Summary
The facility failed to adhere to professional standards of practice by allowing a Certified Nursing Assistant (CNA) to apply ointments to a resident, instead of a Licensed Vocational Nurse (LVN). This occurred for a resident who was at risk of skin breakdown due to conditions such as hemiplegia, hemiparesis, type 2 diabetes mellitus, and epilepsy. The resident required substantial assistance with personal care and was at risk of developing pressure ulcers. During an observation, the CNA was seen applying calmoseptine and vitamin A&D ointments to the resident's skin, which was requested by the resident's family member. The facility also failed to ensure there was a physician's order for the ointments being applied. Interviews with the LVN and the Director of Nursing (DON) confirmed that CNAs were not permitted to apply these ointments and that a physician's order was necessary to ensure there were no contraindications and to monitor the treatment's effectiveness. The facility's policy required that medications be administered only upon a written order from a licensed prescriber, which was not followed in this instance.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident and a family member to the California Department of Public Health, local law enforcement, and the Ombudsman within the required two-hour timeframe as per the facility's policy. The incident involved a verbal altercation between Resident 1 and a family member of Resident 2, which was witnessed by a registered nurse. Despite being informed of the incident, the Director of Nursing did not report it to the appropriate authorities, violating the facility's policy on reporting alleged violations of abuse. Resident 1, who was cognitively intact and capable of making decisions, reported feeling verbally abused after being called derogatory names by the family member of Resident 2. The altercation occurred when Resident 1 was requesting pain medication from a nurse, and the family member intervened, leading to a confrontation. The incident was witnessed by other residents and staff, who confirmed the use of offensive language by the family member. The Director of Nursing acknowledged the incident as a form of abuse and recognized the need to report it to ensure the safety of the residents. However, the failure to document and report the incident in a timely manner as required by the facility's policy resulted in a deficiency. The facility's policy mandates immediate reporting of such incidents to prevent further abuse and ensure resident protection.
Inappropriate Use of Psychotropic Medication for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically Seroquel, which was ordered without a proper diagnosis. The resident, who was admitted with diagnoses including malignant neoplasms and unspecified psychosis, was prescribed Seroquel for false accusations towards staff, despite not being diagnosed with unspecified psychosis by a psychiatrist or medical doctor. The facility's policy requires that psychotropic medications be used only when necessary to treat a specific condition, and non-pharmacological interventions should be attempted first. The resident's Minimum Data Set indicated intact cognition and no evidence of acute mental status changes, delusions, or hallucinations. However, a Change in Condition Evaluation noted increased confusion and hallucinations, leading to a recommendation for a psychiatric consultation. The psychiatric evaluation diagnosed the resident with unspecified schizophrenia spectrum disorder and generalized anxiety disorder, recommending Seroquel. Despite this, the physician's order for Seroquel was based on false accusations, not a specific psychiatric diagnosis, and lacked appropriate behavior monitoring instructions. Interviews with the primary care provider and the Director of Nursing revealed concerns about the appropriateness of the Seroquel order. The primary care provider emphasized the need for a thorough medical work-up and consultation with specialists before diagnosing schizophrenia or psychosis in an elderly resident. The Director of Nursing stated that the order did not target an appropriate behavior and highlighted the risk of sedation and potential abuse. The facility's policy mandates that psychotropic medications should not be used for discipline or convenience and should only be administered when required to treat medical symptoms after non-pharmacological interventions have failed.
Failure to Ensure Call Lights Within Reach for Residents at Risk of Falls
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of three residents, all of whom were at risk for falls, by not ensuring their call lights were within reach. Resident 89, who was admitted with gait abnormalities, mobility issues, and dementia, was observed sitting in a wheelchair with the call light placed on top of the bed and tangled on the side rail, making it inaccessible. The resident's care plan required the call light to be within reach, but this was not adhered to, as confirmed by a Certified Nurse Assistant who had to untangle the cord. Resident 32, who had severe cognitive impairment and was totally dependent on staff for daily activities, was found with a call light on the floor, which was not functioning. The resident's care plan specified that the call light should be attached to the bed within easy access. A Registered Nurse Supervisor confirmed the call light was not working and should have been clipped to prevent displacement. The Maintenance Supervisor stated that call lights were checked weekly, but this did not prevent the issue from occurring. Resident 84, who required substantial assistance and was dependent on staff for transfers, was observed with the call light on the floor under the bed, making it unreachable. The resident expressed difficulty in finding and reaching the call light, and a Certified Nursing Assistant confirmed it was not within reach. The facility's policy required call lights to be placed within reach before staff left the room, but this was not followed, leading to the deficiency.
Failure to Provide Communication Devices for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide appropriate communication devices for two residents, leading to potential communication barriers and delayed care. Resident 50, who was admitted with dementia and a cognitive communication deficit, had a care plan indicating a risk for communication problems due to a language barrier. The care plan included interventions such as writing, using a communication board, gestures, and a translator. However, during an observation, it was noted that the resident spoke Mandarin, and the staff member was communicating through gestures without a communication board available. The staff member acknowledged that Mandarin-speaking staff were not always available, and a communication board was not present in the resident's room. Similarly, Resident 80, who had osteoarthritis and a history of falling, was identified as having a communication problem related to a language barrier. The care plan included assistance with word finding and providing a translator. The resident's preferred language was Taiwanese, and they required an interpreter. During an observation, it was found that the resident did not have a communication board at the bedside, although the staff used an in-person translator and language line. Interviews with the Activity Director and Director of Nursing confirmed that non-English speaking residents should have communication boards to facilitate communication and meet their needs. The facility's policy indicated that communication boards should be provided and kept at the resident's bedside.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to ensure a safe environment for Resident 12 by not implementing the prescribed safety measures. Resident 12, who was admitted with epilepsy and a high risk for falls, had a care plan that included placing floor mats at the bedside and padding the bed side rails for seizure precautions. However, during observations, it was noted that these safety measures were not in place. Licensed Vocational Nurse 1 confirmed the absence of floor mats and padded side rails, acknowledging the risk of serious injury if Resident 12 were to fall or have a seizure. Additionally, the facility did not adhere to its smoking policy for Resident 339, who had moderately impaired cognition and required maximal assistance with daily activities. The care plan for Resident 339 specified that smoking materials should be kept at the nurse's station to prevent injury. However, during an observation, Resident 339 was found in possession of cigarettes, contrary to the facility's policy. Certified Nurse Assistant 1 confirmed that the cigarettes should have been kept with the charge nurse and only provided to the resident during supervised smoking times. Interviews with the Director of Nursing and other staff members further highlighted the facility's failure to follow established policies and procedures for both residents. The facility's policies on fall management and smoking were not implemented as required, posing potential risks to the safety and well-being of Residents 12 and 339.
Failure to Monitor Indwelling Catheters for UTI Symptoms
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding the care and monitoring of residents with indwelling catheters, leading to potential risks of urinary tract infections (UTIs) for three residents. Resident 30, who was admitted with a diagnosis of UTI and obstructive uropathy, had an indwelling catheter that was observed to contain white sediments and cloudy urine. Despite the care plan's directive to monitor for signs of UTI, such as sediment presence and urine cloudiness, these symptoms were not adequately assessed or reported by the nursing staff. Resident 106, admitted with neuromuscular dysfunction of the bladder and paraplegia, also had an indwelling catheter with white sediments observed in the tubing. Additionally, the catheter tubing was kinked, which could obstruct urine flow and increase the risk of infection. The care plan for Resident 106 required monitoring for UTI symptoms, but the presence of sediments and the kinked tubing were not addressed in a timely manner. Similarly, Resident 128, who was admitted with dysphagia and urinary retention, had an indwelling catheter with white sediments observed in the tubing. The care plan indicated the need for regular monitoring for UTI symptoms, yet the presence of sediments was not adequately monitored or reported. The facility's P&P required licensed nurses to assess for UTI signs every shift and ensure unobstructed urine drainage, but these protocols were not followed, leading to potential delays in care and treatment for the residents involved.
Deficiencies in Gastrostomy Tube Management for Two Residents
Penalty
Summary
The facility failed to ensure proper management and care for two residents with gastrostomy tubes (GTs), leading to deficiencies in their treatment. Resident 30, who was admitted with a urinary tract infection and required GT feeding due to swallowing difficulties, had their GT formula bottle unlabeled with the start time. This oversight was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the need for labeling. The Director of Nursing (DON) also confirmed that the GT feeding bottle should be labeled with the date and time it was started. Resident 128, admitted with dysphagia and urine retention, did not receive the prescribed water flush through their GT. The care plan required a 100 ml water flush every four hours, but an observation revealed that the GT pump was not set accordingly. An LVN confirmed the discrepancy and emphasized the importance of following the physician's order to prevent dehydration and electrolyte imbalance. The DON reiterated the necessity of accurate water flushes to prevent dehydration, electrolyte imbalance, and tube clogging. The facility's policies and procedures also outlined the need for proper labeling and routine flushing to prevent tube clogging.
Failure to Attempt Alternatives Before Bed Rail Installation
Penalty
Summary
The facility failed to attempt the use of appropriate alternatives to bed rails before their installation for two residents, placing them at risk for entrapment and injury. Resident 99 was readmitted with diagnoses including diabetes mellitus and anxiety disorder. Observations revealed that bed rails were up on both sides of her bed since readmission, despite her ability to get out of bed independently. The Director of Nursing (DON) confirmed that the medical record lacked documentation of attempted alternatives to bed rails, such as low beds or foam bumpers, before their use. Similarly, Resident 26, who was readmitted with dementia and chronic obstructive pulmonary disease, had bed rails installed without documented attempts of alternatives. The resident was on antipsychotic medication for psychosis and exhibited behaviors like striking out at staff. The DON acknowledged the absence of documented evidence of alternatives being tried and noted the potential hazards of bed rails, especially for residents with behavioral issues. The facility's policy required alternatives to be attempted before bed rail installation, which was not followed in these cases.
Improper Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food sanitation and safe handling practices, as observed during a survey. In the facility's kitchen, a container of raw ground turkey was placed on the lowest shelf of the walk-in refrigerator next to a container of ready-to-eat chopped carrots. This arrangement was contrary to the facility's policy and procedure, which mandates that ready-to-eat foods should be stored above raw meats to prevent contamination from raw-product juices. The Certified Dietary Manager (CDM) acknowledged that this practice could lead to food contamination and potential foodborne illnesses among residents. Additionally, the facility's kitchen staff placed used spoons with food particles in the same rack as clean knives, which was observed during the survey. This practice was also against the facility's sanitation policy, which requires all utensils to be kept clean to prevent cross-contamination. The CDM confirmed that placing used utensils with clean ones could cause cross-contamination, posing a risk of foodborne illness to the residents.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information on Advance Directives (AD) for one of the sampled residents, identified as Resident 48. This deficiency was identified during a review of Resident 48's Admission Record and Medical Record, which showed no documentation of AD acknowledgment. Resident 48 was readmitted to the facility with diagnoses including dysphagia and dementia, and the Minimum Data Set indicated that the resident had unclear speech, rarely understood others, and was dependent on assistance for daily activities. Despite these conditions, there was no evidence that AD information was offered to Resident 48 or their responsible party. During an interview, the Social Service Director confirmed the absence of documentation regarding AD information being provided to Resident 48 or their representative. The facility's policy, revised in December 2023, requires that residents or their representatives be given written information about their rights to accept or refuse treatment and to formulate ADs upon admission. The lack of documentation in Resident 48's medical record suggests a failure to adhere to this policy, potentially leading to treatment being administered against the resident's will.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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