Palomar Heights Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Escondido, California.
- Location
- 1260 E Ohio Avenue, Escondido, California 92027
- CMS Provider Number
- 555764
- Inspections on file
- 35
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Palomar Heights Post Acute during CMS and state inspections, most recent first.
A resident with heart failure was discharged home with a documented post-discharge PCP appointment, but the appointment was not explained to the resident or family. The case manager scheduled the PCP visit but did not review it with the resident, believing this was the responsibility of the LPN completing the discharge. The LPN who discharged the resident did not discuss the appointment, believing it was the case manager’s responsibility. The DON later stated both the case manager and LPN should have communicated the scheduled PCP visit, and the facility’s transfer/discharge policy lacked guidance on discharge planning and communication of the discharge plan.
A resident with heart failure had daily orders for three antihypertensive medications (amlodipine, isosorbide mononitrate ER, and lisinopril) that were to be held if systolic BP was below 110. On one occasion, an LN documented administering all three medications when the resident’s systolic BP was 106, contrary to the prescriber’s parameters. In a later interview, the LN did not recall giving the medications under those conditions, and the DON confirmed the medications should have been held. This failure to follow ordered BP parameters did not comply with the facility’s medication administration policy and placed the resident at increased risk of medication side effects.
A resident with a G-tube and seizure history was found lying in bed with eyes closed while a clear plastic cup containing crushed medications mixed in liquid was left unattended on the bedside table. Physician orders required morning administration of ascorbic acid, furosemide with blood pressure parameters, and a multivitamin via G-tube, and the MAR showed these medications as given. An LN reported leaving the medications at the bedside to dissolve further and acknowledged they should not have been left there, while the DON stated medications must not be left unattended in resident rooms. The facility’s medication storage policy required locked compartments for biologicals when not in use and specified that items shall not be left unattended, which conflicted with the observed practice.
A resident with a G-tube and seizure diagnosis was found lying in bed with a cup of crushed medications mixed in liquid left unattended on the bedside table, while the MAR showed the morning doses of ascorbic acid, furosemide, and a multivitamin as already administered via G-tube. An LN reported leaving the medications to further dissolve after giving water and had documented them as given, and the DON confirmed medications should not be left unattended and that documentation must reflect when drugs are withheld or given at unscheduled times. This resulted in inaccurate medical record documentation contrary to facility policy and prescriber orders.
Multiple deficiencies were identified in medication administration and documentation, including late administration of aspirin for a resident, improper technique for nasal spray administration, failure to verify G-tube placement and use gravity for medication delivery, and unaccounted controlled medications for two residents due to incomplete documentation and lack of reconciliation between records.
Surveyors found that expired insulin was stored in a medication cart, ipratropium/albuterol inhalation vials were left exposed to light in an open box, and a box of ampicillin vials was kept unlabeled in a medication room drawer. Nurses and nursing leadership confirmed these practices did not meet facility policy or manufacturer guidelines for medication storage and labeling.
Multiple residents reported that meals were often served cold, lacked taste, and were unattractive, with some avoiding facility food altogether. Surveyors confirmed these concerns through interviews and a test tray evaluation, finding that while food temperature was acceptable, the main entrée was tasteless, and the Dietary Services Supervisor agreed with this assessment.
The QAA Committee did not identify or include trends related to resident nail care, grooming, and annual staff performance evaluations in the QAPI plan, despite these deficiencies being found by surveyors. The DON confirmed that the QAPI team was only monitoring call lights, falls, and UTIs, and had not addressed the additional areas as required by facility policy.
A resident with swallowing difficulties was fed by a CNA who stood over the bed instead of sitting at eye level, contrary to facility policy and staff training. Staff interviews confirmed the expectation to sit while feeding to maintain dignity, but the CNA did not comply due to lack of a chair in the room.
Two residents, one with COPD and dementia and another with a corneal ulcer and vision impairment, were not properly assisted with or offered Advance Directives (AD) upon admission. Facility staff failed to document whether ADs were requested, accepted, or declined, despite policy requirements and resident reports that assistance was not provided. This resulted in a deficiency related to honoring residents' rights regarding healthcare preferences.
Several residents experienced deficiencies in their living environment, including unaddressed maintenance issues such as a leaking toilet, missing caulking, a hole in the wall, and cobwebs in vents, as well as the failure to replace or reimburse lost clothing. Staff interviews confirmed that these concerns were not properly documented or addressed, resulting in an environment that was not clean, well-maintained, or homelike.
A resident with a history of pulmonary fibrosis showed improvement in ADLs, but the IDT did not timely review or determine the need for a Significant Change of Status Assessment (SCSA), and the care plan was not updated to reflect these changes. The MDS nurse confirmed the SCSA was not discussed or completed on time, and the physician was not notified of the improvement.
A resident with a history of pulmonary fibrosis did not have their MDS and CAA assessments completed and transmitted within the federally required 14-day timeframe. The MDS nurse and DON confirmed the delay, which could have led to delays in care planning and unmet care needs.
A resident with a history of major depressive disorder and moderate cognitive deficits did not have their care plan updated to reflect their preferred social activities or participation frequency. The Activities Director was unaware of the need to revise activity care plans after reassessments, and the care plan had not been updated in nearly a year, despite the resident's expressed interests and needs for assistance.
A resident with a history of pulmonary fibrosis was re-admitted and experienced improvement, but the care plan was not updated after a Significant Change of Status Assessment (SCSA). The MDS nurse did not complete required assessments on time, and the DON confirmed that care plans should be updated promptly to reflect current conditions, as outlined in facility policy.
Three residents who were unable to perform personal hygiene tasks independently were observed with long, dirty fingernails, and in some cases, requested assistance with nail care that was not provided. Staff interviews confirmed that nail care was not performed as needed, and facility policy requiring daily cleaning and regular trimming was not followed.
A resident with moderate cognitive deficits and a history of major depressive disorder did not consistently receive meaningful activities aligned with her preferences, such as social gatherings and assistance with mobility, due to lapses in activity planning and care plan updates. The AD did not update the activity care plan after reassessments, and activities were not provided as frequently as documented in the resident's plan, resulting in unmet psychosocial needs.
A resident with muscle weakness and chronic venous hypertension experienced pain when a CNA used a Hoyer lift to weigh the resident without a second staff member present, resulting in the lift striking the resident's left knee. Staff interviews and facility policy confirmed that two staff are required for safe use of the mechanical lift, but this protocol was not followed.
A resident with PTSD and a history of traumatic brain injury, seizures, and repeated falls did not receive trauma-informed care as required. Direct care staff, including a CNA and charge nurse, were unaware of the resident's PTSD diagnosis and specific triggers, and there was no scheduled staff training on PTSD. Although the Social Service Director maintained a PTSD care plan binder, several staff members did not know about it or the expectation to review it, resulting in a failure to minimize the resident's exposure to trauma triggers.
The facility did not complete required annual performance evaluations for two CNAs, as confirmed by record review and staff interviews. Despite facility policy mandating annual evaluations after the probationary period, these evaluations were missing for multiple years for both CNAs.
A licensed nurse did not consistently verify meal tray contents against tray cards before distribution, only checking trays for therapeutic diets and not for regular diets or allergies. This resulted in a failure to ensure residents received the correct diets as ordered.
A licensed nurse did not document an incident where a resident with cognitive impairment was found sitting on the floor after reportedly losing balance and being assisted by staff. The DON confirmed that such incidents should be documented as falls, but no record was made in the clinical file.
A resident with end-stage stroke was admitted with orders for hospice care, but the facility failed to ensure timely communication and awareness of the resident's hospice certification status. The Social Service Director, responsible for coordinating hospice care, was unaware that the physician's certification had expired, and staff interviews confirmed that re-certification is necessary for continued hospice services. This lapse indicated a breakdown in the process for coordinating and documenting hospice care.
Staff did not discard an unlabeled IV hydration bag and uncapped IV tubing left hanging at a resident's bedside, despite the resident not having an active IV line. The equipment remained in the room for several days, and the resident had a history of HIV and moderate cognitive deficits. The ICPN and DON confirmed the items should have been labeled and removed, but the facility's infection control policy lacked guidance on IV equipment disposal.
The facility failed to develop and implement adequate policies for influenza and pneumococcal immunizations, neglecting to provide necessary education to residents or their representatives and failing to document immunization status in medical records. This oversight includes not offering influenza immunizations during the required period and not ensuring pneumococcal immunizations were administered unless contraindicated.
A resident with a below-the-knee amputation fell while transferring from bed to a wheelchair with nonfunctioning brakes. Despite the resident's report, the issue was not logged or addressed by the facility's maintenance team. Observations confirmed the brakes were faulty, and the facility's policies on equipment maintenance were not followed, contributing to the fall.
A resident with a below-the-knee amputation fell while transferring from bed to a wheelchair due to malfunctioning brakes. Despite the resident's report, the wheelchair brakes remained unfixed. Staff confirmed the brake issue, and the maintenance log showed no prior reports, indicating a lapse in equipment maintenance and reporting.
A resident with congestive heart failure and ischemic cardiomyopathy was found unresponsive and later pronounced deceased after the facility failed to assess a change in condition and notify the physician. The resident had refused a shower, appeared pale and sweaty, but the licensed nurse did not follow up on vital signs or assess the condition due to being busy. The facility's policy required prompt notification and assessment, which was not adhered to.
Failure to Communicate Post-Discharge PCP Appointment to Resident
Penalty
Summary
The facility failed to ensure that a resident’s discharge plan, specifically a scheduled post-discharge primary care physician (PCP) appointment, was explained to the resident or family. A resident admitted with diagnoses including heart failure was discharged home on 4/3/26. The facility’s Discharge Summary and Post-Care Instructions dated 4/2/26 documented that the resident had a PCP appointment scheduled for 4/7/26. During interview, the Case Manager stated she scheduled the PCP appointment but did not discuss it with the resident or family, indicating she believed it was the Licensed Nurse’s responsibility at discharge. The Licensed Nurse who conducted the discharge stated she did not discuss the PCP appointment with the resident or family, believing it was the Case Manager’s responsibility prior to discharge. The Director of Nursing stated that both the Case Manager, during discharge planning, and the Licensed Nurse, at the time of discharge, should have discussed the scheduled PCP appointment with the resident. The facility’s Transfer or Discharge policy, revised March 2025, did not include instructions on discharge planning or communicating the discharge plan to the resident. As a result, the resident may not have been aware of the scheduled post-discharge PCP appointment.
Failure to Follow Blood Pressure Parameters for Antihypertensive Medications
Penalty
Summary
The facility failed to ensure medications were administered as ordered when a resident with heart failure was given multiple antihypertensive medications despite a documented systolic blood pressure below the ordered hold parameter. According to the admission record, the resident was admitted with diagnoses including heart failure and later discharged from the facility. The March 2026 MAR showed daily orders for amlodipine 5 mg, isosorbide mononitrate ER 30 mg, and lisinopril 5 mg, with instructions not to administer these medications if the resident’s systolic blood pressure was less than 110. On 3/1/26, LN 2 documented administering all three medications when the resident’s systolic blood pressure was 106. In a subsequent telephone interview, LN 2 stated she did not remember giving the blood pressure medications when the systolic blood pressure was less than 110, and the DON stated that LN 2 should have held the medications when the systolic blood pressure was below 110. Per the facility’s “Administering Medications” policy, medications are to be administered in accordance with prescriber orders and medication errors are to be documented, reported, and reviewed. As a result of this failure to follow the ordered blood pressure parameters, the resident was placed at an increased risk of medication side effects.
Unattended Medications Left at Bedside
Penalty
Summary
Surveyors identified a deficiency related to medication storage and administration when a resident’s crushed medications mixed in a tea-colored liquid were observed in a clear plastic cup left unattended on the bedside table. During an unannounced complaint visit, the resident was observed lying in bed with eyes closed while the medication cup remained at the bedside. The resident’s admission record showed diagnoses including attention to gastrostomy and seizures, and the MDS assessment had a blank BIMS cognition section. Physician orders indicated the resident was to receive ascorbic acid 500 mg, furosemide 40 mg with parameters to hold for systolic blood pressure less than 100, and a multivitamin with minerals, all to be administered via G-tube in the morning. The MAR for the same date showed these medications as administered and signed off by a licensed nurse. In an interview, the licensed nurse stated she had left the medications on the bedside table to further dissolve in water and acknowledged she should not have left them in a clear cup at the bedside because some residents or someone might pick them up and swallow them. The DON stated that medications should not be left anywhere in resident rooms unattended and emphasized this was important for resident safety. Review of the facility’s “Storage of Medications” policy stated that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, that compartments containing biologicals shall be locked when not in use, and that items shall not be left unattended. The observed practice of leaving medications unattended at the bedside was inconsistent with this policy.
Inaccurate MAR Documentation and Unattended Medications at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical record documentation when a resident’s medications were documented as administered despite being left unattended at the bedside. During an unannounced complaint visit, a resident with a gastrostomy tube and seizure diagnosis was observed lying in bed with eyes closed, while a clear plastic cup containing crushed medications mixed in a tea-colored liquid was found on the bedside table. The resident’s MDS showed the BIMS cognition section was blank. Physician orders directed that several medications, including ascorbic acid, furosemide (with a hold parameter for SBP <100), and a multivitamin with minerals, be given via G-tube in the morning. The MAR for that morning indicated these medications were administered and signed off by a licensed nurse as given. In an interview, the licensed nurse stated she had left the medications on the bedside table to further dissolve in water she had administered earlier and had already documented the medications as given on the MAR. The DON stated that medications should not be left unattended in any resident rooms and confirmed that the nurse had documented the medications as administered via G-tube. The facility’s “Administering Medications” policy stated that only appropriately licensed personnel may prepare, administer, and document medications, that medications are to be administered in accordance with prescribers’ orders, and that if a drug is withheld, refused, or given at a time other than scheduled, the individual administering the medication must document this. The observed practice and documentation for this resident were inconsistent with these requirements, resulting in inaccurate medical record documentation.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice for several residents. For one resident, aspirin prescribed as a stroke prophylaxis was administered outside the one-hour window specified by the physician's order, with documentation showing the medication was given over two hours late. Both the licensed nurse and the Director of Nursing acknowledged the importance of timely administration and adherence to physician orders, as outlined in facility policy. Another resident received Fluticasone nasal spray for allergies, but the administration did not follow the manufacturer's instructions. The nurse instructed the resident to tilt her head back instead of forward, contrary to the packaging insert. Both the nurse and the Director of Nursing confirmed that following manufacturer guidelines is necessary for medication effectiveness, and the nurse admitted to not following the correct procedure during administration. A third resident with a G-tube did not have proper placement verification before medication administration, as the nurse used water instead of air for auscultation and administered medication using a syringe/plunger rather than by gravity, which is against facility policy. Additionally, for two other residents, controlled medications could not be accounted for due to discrepancies between the controlled drug record and the electronic medication administration record. The nurses and Assistant Director of Nursing confirmed that documentation was incomplete and that required audits and reconciliations were not performed, as required by facility policy.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure medications were stored and labeled according to accepted standards of practice. During inspection of two medication carts and one medication room, expired insulin was found stored in a medication cart, and a nurse acknowledged it should have been discarded after 28 days due to potential loss of potency. Additionally, ipratropium/albuterol inhalation vials were stored in an open box, exposing them to light, contrary to manufacturer instructions to keep them protected from light. The nurse responsible for the cart confirmed the box should have been closed to prevent light exposure. In the medication room, a box of ampicillin vials was found inside a drawer without a medication label, stored alongside unrelated items such as a plastic bag and a pen. The nurse present was unaware of the reason for the unlabeled storage. The Assistant Director of Nursing stated that the ampicillin should have been labeled with the resident's name and other required information, and the Director of Nursing confirmed that expired insulin and improperly stored medications should have been discarded. Facility policy and manufacturer guidelines reviewed by surveyors supported these requirements for medication labeling and storage.
Deficiency in Food Palatability and Temperature
Penalty
Summary
Surveyors identified a deficiency related to the preparation and serving of food, based on both resident interviews and direct observation. Multiple residents reported that the food was often served cold, lacked taste, and was unattractive in appearance. Specific complaints included food being cold at breakfast, unappetizing combinations, insufficient variety, and poor presentation. Some residents stated they avoided eating the facility's food, with one resident relying on family to bring in meals. These concerns were echoed during a confidential group interview, where residents noted that food quality was particularly poor on weekends when the supervisor was not present. To verify these complaints, surveyors conducted a test tray evaluation during a lunch service. The test tray was assessed for temperature and taste by both the surveyor and the Dietary Services Supervisor (DSS). While the temperature of the food was found to be palatable, the roast turkey was described as tasteless, a finding with which the DSS agreed. The report documents that the facility failed to cook food in a way that preserved its palatability, leading to resident dissatisfaction and the potential for decreased food intake.
QAA Committee Failed to Identify and Address Deficient Trends in QAPI Plan
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to identify and include certain quality deficiencies in the Quality Assurance Performance Improvement (QAPI) plan. Specifically, during a recertification and relicensing survey, surveyors identified trends related to resident nail care, grooming, and annual staff performance evaluations that were not being monitored or addressed by the QAA Committee. The Director of Nursing (DON) confirmed that the QAPI team was primarily focused on call lights, falls, and urinary tract infections, and had not recognized or prioritized the additional deficient trends found by surveyors. Facility policy requires the QAPI program to address all systems and practices affecting residents, including clinical care, quality of life, and staff performance, and to prioritize high-risk or problem-prone areas. However, the QAA Committee did not identify or include the surveyor-identified trends in their QAPI plan, contrary to policy expectations. This omission was acknowledged by the DON during interviews and was supported by a review of the facility's QAPI documentation.
Failure to Promote Resident Dignity During Feeding Assistance
Penalty
Summary
A deficiency was identified when a resident with dysphagia and oropharyngeal swallowing difficulties was not provided care in a manner that promoted dignity and respect during mealtime. During an observation, two CNAs assisted the resident with breakfast while the resident was in bed. One CNA fed the resident while standing next to the bed, rather than sitting at the resident's eye level. The CNA acknowledged that she was taught to sit while feeding residents to promote dignity but did not do so because there was no chair available in the room. Interviews with staff, including another CNA, the Director of Staff Development, and the Director of Nursing, confirmed that the facility's expectation and policy require staff to sit at the resident's eye level when providing feeding assistance. The facility's policy on meal assistance specifically states that residents should be fed with attention to safety, comfort, and dignity, and not while standing over them. The failure to follow this policy resulted in care that did not honor the resident's right to dignity.
Failure to Assist with or Document Advance Directives for Two Residents
Penalty
Summary
The facility failed to assist with or obtain Advance Directives (AD) for two residents, resulting in a deficiency related to honoring residents' rights to specify their healthcare preferences. For one resident with a history of COPD and dementia, the Social Service Director acknowledged that while a Physician Orders for Life Sustaining Treatment (POLST) was present in the clinical record, there was no AD on file. The Admissions Coordinator was unable to find documentation that an AD was requested, refused, discontinued, or offered, and only a consent to treat form was signed by the resident's responsible party. The Director of Nursing confirmed that it was expected for ADs to be part of the clinical chart and emphasized the importance of knowing who would be responsible for healthcare decisions. For another resident admitted with a corneal ulcer and blindness in one eye, the Director of Nursing and Admissions Director both confirmed that there was no documentation of an AD being offered, accepted, or declined. The resident reported that the admission agreement was read quickly and that he was not offered assistance with creating an AD, despite the facility's policy stating that staff would offer such assistance and document the resident's decision. The lack of documentation and failure to offer or assist with ADs for these residents constituted the identified deficiency.
Failure to Maintain Safe and Homelike Environment and Replace Lost Belongings
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four residents. One resident reported missing three shirts, which were not replaced or reimbursed by the facility despite being reported to staff. The Social Services Director stated the shirts were not replaced because they were not listed on the belongings sheet, although the resident's belongings sheet did indicate shirts were present. The Administrator later acknowledged that the shirts should have been replaced. As a result, the resident did not have enough shirts for daily use. Additionally, three other residents experienced issues with the cleanliness and maintenance of their living environment. One resident and his roommate reported a leaking toilet, missing caulking, a missing baseboard, and cobwebs in the bathroom vent. Another resident reported a hole in the wall behind his door that had been present since admission. Observations confirmed these deficiencies, and staff interviews revealed that maintenance issues were not documented in the maintenance binder as required. The Maintenance Supervisor admitted to not having time to address these issues and not conducting regular room checks. The Director of Nursing confirmed that the environment should be visually appealing and that the reported issues should have been addressed.
Failure to Timely Assess and Update Care Plan After Resident's Significant Change in Condition
Penalty
Summary
The facility failed to properly assess and document a significant change in condition for a resident who was re-admitted with a history of pulmonary fibrosis. Despite evidence of improvement in activities of daily living (ADLs) such as eating, oral hygiene, and toileting, the Interdisciplinary Team (IDT) did not review or determine the need for a Significant Change of Status Assessment (SCSA) during the comprehensive skilled review. The Minimum Data Set (MDS) nurse confirmed that the SCSA was not discussed or initiated in a timely manner, and the care plan was not updated to reflect the resident's improvement as required by the Resident Assessment Instrument (RAI) manual. Additionally, the care plan for the resident's ADLs, last revised prior to the improvement, did not include updated information from the SCSA. The MDS nurse also stated that the resident's physician was not notified of the improvement, and the IDT did not solidify whether an SCSA was appropriate during their review. The Director of Nursing indicated that the expectation was for the IDT and MDS nurse to know and apply the criteria for SCSA and to discuss significant changes in status for all residents, but this did not occur in this instance.
Late Completion of MDS and CAA Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) and Care Area Assessment (CAA) within the required timeframe for one resident. Specifically, the MDS and CAA for a resident who was re-admitted with a history of pulmonary fibrosis were not completed and transmitted to the state within 14 days of the assessment reference date, as mandated by federal regulations. Record review showed that the assessment completion and care plan updates were late, with the MDS nurse confirming that the required assessments had not been completed on time. Interviews with the MDS nurse and the Director of Nursing confirmed that the assessments and care plan updates were delayed, which could have resulted in delays in care planning and unmet care needs for the resident. The MDS nurse acknowledged that the late completion of the MDS could have delayed necessary care updates and may have impacted the resident's ability to maintain or improve their independence in activities of daily living.
Failure to Update Person-Centered Care Plan for Resident Activities
Penalty
Summary
The facility failed to develop a person-centered care plan that addressed all of a resident's needs, specifically neglecting to include the resident's preferred activities. The resident, who had a history of major depressive disorder and moderate cognitive deficits, expressed a desire to participate in social activities such as bingo and coffee gatherings but required assistance to get out of bed and to change into her own clothing. Despite these expressed preferences and needs, the care plan had not been updated since the previous year and did not reflect the resident's current activity interests or participation frequency as indicated in her activity participation review. Interviews with the Activities Director (AD) revealed a lack of awareness regarding the need to update activity care plans following quarterly and comprehensive reassessments. The AD acknowledged the importance of updating care plans to support residents' mental and physical well-being but had not done so for this resident. The Director of Nursing (DON) confirmed that activity preferences should be established through resident interviews and incorporated into individualized care plans, and that the AD should contribute to these updates as part of the interdisciplinary team. The facility's policy also required resident participation in care planning, including determining the type, amount, frequency, and duration of care.
Failure to Update Care Plan After Significant Change Assessment
Penalty
Summary
The facility failed to update the care plan for one resident following a Significant Change of Status Assessment (SCSA), as required by federal guidelines. The resident, who had a history of pulmonary fibrosis and was re-admitted to the facility, experienced an improvement in their condition that was not reflected in the revised care plan dated 1/25/25. A review of the clinical chart showed that the care plan for activities of daily living (ADL) did not include updated information from the SCSA regarding the resident's improvement. Interviews with facility staff revealed that the MDS nurse acknowledged the required assessments, including the MDS and CAA, were not completed on time, and the care plan was not updated to reflect the resident's improved self-care abilities. The DON confirmed the importance of timely completion of these assessments and care plan updates to ensure they reflect the resident's current condition. The facility's policy also requires the interdisciplinary team to review and update care plans when there is a significant change in a resident's condition.
Failure to Provide Adequate Nail Care and Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically nail care and shaving, for three residents who were unable to perform these tasks independently. Observations and interviews revealed that one resident with hemiplegia and hemiparesis had long fingernails with debris underneath and expressed a desire to have her nails trimmed. A CNA confirmed that nail care was scheduled weekly and acknowledged the risk of fungus and bacteria from long nails. Another resident, dependent on staff for personal hygiene due to muscle weakness and lymphedema, had long fingernails with black debris and requested staff assistance to clean under his nails. A licensed nurse also confirmed the need for nail cleaning for hygiene purposes. A third resident with Parkinsonism, requiring substantial assistance with personal hygiene, was observed with long fingernails and black debris under the nails. Both the resident and a treatment nurse confirmed the need for nail trimming and cleaning for infection control. The Director of Nursing stated that residents' fingernails should be kept short and clean to prevent skin tears and infections. Review of the facility's policy indicated that nail care should include daily cleaning and regular trimming, which was not consistently provided to these residents.
Failure to Provide Resident-Centered Activities Based on Assessment and Preferences
Penalty
Summary
The facility failed to provide meaningful activities that matched the preferences and needs of a resident with a history of major depressive disorder and moderate cognitive deficits. The resident, who required assistance to get out of bed and preferred social activities such as bingo and coffee gatherings, reported uncertainty about participating in activities due to inconsistent assistance with mobility and personal care, such as not being helped to change into her own clothing. Interviews and record reviews revealed that the Activities Director (AD) did not consistently offer or document activities according to the resident's stated preferences and care plan, particularly during March and April. The AD acknowledged that activities were not provided as preferred and that the resident's care plan interventions had not been updated since the previous year, despite quarterly and comprehensive assessments being conducted. Further, the AD was unaware of the need to update activity care plans following reassessments, and the facility's policy required activities to be based on comprehensive, resident-centered assessments and preferences. The Director of Nursing (DON) confirmed that activities should be tailored to each resident's preferences and that the AD should update care plans as part of the interdisciplinary team. The lack of updated care plans and failure to provide activities as preferred resulted in the resident not receiving adequate social and meaningful engagement as outlined in her care plan and facility policy.
Failure to Provide Adequate Supervision During Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with muscle weakness, chronic venous hypertension, and arthritis in the left knee experienced pain during a transfer using a Hoyer lift. The incident happened when a Certified Nurse Assistant (CNA) weighed the resident using the lift without a second staff member present, contrary to facility policy and staff training, which require two people for safe operation of the mechanical lift. The resident reported that the sling was not applied correctly and the metal part of the lift struck his left knee, causing pain. Interviews with staff, including the Restorative Nurse Assistants (RNAs), Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that the expectation and policy is for two staff members to be present when using a Hoyer lift. The CNA involved in the incident proceeded alone because other CNAs were on break, despite being aware of the two-person requirement. Review of the facility's policy further supported that at least two nursing assistants are needed to safely move a resident with a mechanical lift.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for one resident diagnosed with Post Traumatic Stress Disorder (PTSD) among a sample of 24 residents. The resident had a history of traumatic brain injury, repeated falls, seizures, and PTSD, with documented triggers including feeling belittled due to a history of abusive relationships and anxiety related to car rides following multiple car accidents. The care plan identified these triggers and the need to minimize exposure to them. However, interviews with staff revealed that direct care staff, including a CNA and a charge nurse, were unaware of the resident's PTSD diagnosis, her specific triggers, or the location of the PTSD care plan binder. The medication nurse was aware of the PTSD diagnosis but did not know the resident's specific triggers. The Social Service Director confirmed knowledge of the resident's PTSD and triggers and stated that this information was available in a PTSD binder on the unit, which staff were expected to review. Despite this, the Director of Staff Development acknowledged that there were no scheduled in-services on PTSD for the year, and several staff members were unaware of the PTSD binder or the expectation to review it. The Director of Nursing stated that staff should be familiar with residents' PTSD history and triggers and that this information should be care planned and accessible. Facility policy required assessment and care planning to minimize exposure to trauma triggers, but staff interviews and record review demonstrated that this was not consistently implemented.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for two out of five Certified Nurse Assistants (CNAs) whose records were reviewed. Specifically, one CNA hired in April 2023 did not have performance evaluations for 2024 and 2025, and another CNA hired in January 2022 did not have evaluations for 2023 and 2025. This was confirmed during a record review and interviews with the Director of Staff Development and the Director of Nursing, both of whom acknowledged the importance of annual evaluations for assessing employee attendance, skills, goals, and training needs. The facility's policy requires performance evaluations at the end of a 90-day probationary period and at least annually thereafter, but this policy was not followed for the CNAs in question.
Failure to Verify Meal Tray Diets by Licensed Nurse
Penalty
Summary
The facility failed to ensure that meal tray diets were properly verified by a licensed nurse prior to distribution to residents. On 5/28/25, lunch trays were delivered to the floor, and a licensed nurse was observed checking only a few trays by lifting their lids and comparing the contents to the tray cards. The nurse did not open every tray to confirm the food matched the tray card for each resident. During an interview, the nurse stated that she only checked trays for therapeutic diets that could prevent choking and did not verify the contents of regular trays or check for allergies or specific resident requests. As a result, there was a failure to confirm that each resident received the correct diet as ordered, including consideration for allergies and special dietary needs, as required by facility policy.
Failure to Document Resident Fall Incident
Penalty
Summary
A licensed nurse failed to document an incident involving a resident who was found sitting on the floor in her room. The resident, who had a history of stroke, vascular dementia, and mild cognitive impairment, reported to her responsible party that she had fallen and hit her head the previous night, and that two staff members assisted her to get up. The responsible party relayed this information to the Assistant Director of Nursing, who stated there was no report of a fall. When interviewed, the resident confirmed she had lost her balance, fallen, and was helped by staff, but denied any injury. The nurse who found the resident on the floor stated that the resident claimed she had chosen to sit on the floor because she did not have a chair, and the nurse assisted her to a chair without documenting the incident in the clinical record. Another nurse indicated she would have assessed and documented if she had found the resident on the floor. The Director of Nursing stated that any incident of a resident being found on the floor should be documented as a fall, regardless of the resident's explanation. A review of the facility's fall policy did not provide guidance on documentation for such incidents.
Failure to Ensure Timely Hospice Certification and Communication
Penalty
Summary
The facility failed to ensure there was a process for communicating hospice services for one of two residents reviewed for hospice services. A resident with a history of hemiplegia and hemiparesis following a cerebral infarction was admitted with physician orders to receive hospice care for end-stage stroke. During review, it was found that the physician's certification for hospice had expired, and the Social Service Director (SSD), who was responsible for coordinating hospice care, was not aware of the expired certification. Despite the expiration, the SSD believed the resident was still under hospice care. Interviews with facility staff, including a licensed nurse and the Director of Nursing (DON), revealed that hospice re-certification is necessary to determine continued eligibility for hospice services. The facility's policy indicated that obtaining physician certification and recertification is required for each resident under hospice care. However, the lack of awareness and communication regarding the expired certification demonstrated a breakdown in the process for ensuring proper coordination and documentation of hospice services for the resident.
Failure to Discard Unlabeled IV Equipment and Maintain Infection Control
Penalty
Summary
Facility staff failed to follow proper infection control practices by not discarding an unlabeled intravenous (IV) hydration bag and uncapped IV tubing that was left hanging in a resident's room. Over several days, observations confirmed that the IV bag, which was undated and unlabeled, remained attached to an IV pole at the resident's bedside, despite the resident not having an active IV line. The IV tubing was also uncapped and unlabeled. The resident, who had a history of HIV and moderate cognitive deficits, shared the room with two other residents. Multiple observations and interviews with the resident, staff, and the Infection Control Prevention Nurse (ICPN) confirmed the presence of the IV equipment and the lack of labeling or proper disposal. The ICPN and Director of Nursing (DON) acknowledged that the IV hydration and tubing should have been labeled and discarded immediately, and that the IV pole should have been cleaned and stored properly. The facility's infection control policy did not provide guidance on the proper storage and disposal of IV devices and equipment. The failure to remove and properly dispose of the IV equipment was identified through direct observation, interviews, and record review, and was recognized by facility staff as an infection control issue.
Deficiency in Immunization Policies and Procedures
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to develop and implement adequate policies and procedures for influenza and pneumococcal immunizations. Specifically, the facility did not ensure that each resident or their representative received education regarding the benefits and potential side effects of these immunizations before they were offered. Additionally, the facility failed to document in the residents' medical records whether the education was provided, whether the immunizations were administered, or if they were refused due to medical contraindications or personal choice. The report highlights that the facility did not offer influenza immunizations to residents between October 1 and March 31 annually, as required, nor did it ensure that pneumococcal immunizations were offered unless contraindicated or previously administered. This lack of compliance with regulatory requirements indicates a significant oversight in the facility's immunization practices, potentially impacting the health and safety of the residents.
Failure to Maintain Wheelchair Brakes Leads to Resident Fall
Penalty
Summary
The facility failed to prevent a fall incident involving a resident who was transferring from bed to a wheelchair with nonfunctioning brakes. The resident, who had a below-the-knee amputation and was hard of hearing, attempted to transfer independently but fell when the wheelchair moved despite the brakes being locked. The resident reported the incident and noted that the wheelchair brakes were still not fixed at the time of the survey. Observations and interviews with staff confirmed that the wheelchair's brakes were not functioning properly, allowing the wheels to move even when the brakes were engaged. The process for reporting broken equipment was not followed, as the issue with the wheelchair brakes was not logged in the maintenance book, and the Director of Maintenance was not notified. The facility's maintenance log showed no record of the wheelchair brakes being reported as broken prior to the survey. The facility's policies on fall risk management and maintenance of assistive devices were not adhered to, as there was no regular maintenance or inspection of the resident's wheelchair brakes. The interdisciplinary team did not address the malfunctioning brakes in their notes following the fall, and the care plan did not include interventions to ensure the wheelchair brakes were functioning properly. This oversight contributed to the resident's fall and the potential for further injury.
Failure to Maintain Wheelchair Brakes Leads to Resident Fall
Penalty
Summary
The facility failed to maintain a wheelchair in proper working condition, leading to a fall incident involving a resident. The resident, who had a below-the-knee amputation and was hard of hearing, attempted to transfer from bed to the wheelchair. Despite the brakes being locked, the wheelchair moved, causing the resident to fall. The resident reported the incident and stated that the wheelchair brakes were still not functioning properly. Multiple staff members, including CNAs, the Director of Maintenance (DOM), and the Director of Nursing (DON), confirmed that the wheelchair's brakes were not functioning as expected. The DOM acknowledged that the facility provided the wheelchair and that he would check the brakes if a problem was reported, but there was no regular maintenance schedule for wheelchair brakes. The maintenance log did not contain any prior reports of the wheelchair's brake issues, indicating a lapse in the reporting and maintenance process. The facility's policies on fall risk management and assistive devices emphasize the importance of maintaining equipment to prevent accidents. However, the maintenance log and wheelchair cleaning schedule showed no documentation of the wheelchair needing or receiving repairs. The interdisciplinary team note following the resident's fall did not address the inspection or repair of the wheelchair, highlighting a gap in the facility's response to the incident.
Failure to Assess and Notify Physician of Change in Condition
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for a resident with congestive heart failure and ischemic cardiomyopathy. The resident was admitted with these diagnoses and was found unresponsive during a night shift. The certified nurse assistant (CNA) reported the unresponsiveness to the charge nurse, who initiated cardiopulmonary resuscitation (CPR) and called 911. Paramedics arrived shortly after and pronounced the resident deceased. Prior to this incident, the resident had refused a shower during the afternoon shift, citing not feeling well, and appeared pale and sweaty. The CNA reported this to the licensed nurse (LN) on duty, who instructed the CNA to take the resident's vital signs (VS). However, the LN did not follow up on the VS or assess the resident's condition due to being busy. The resident's symptoms of sweating and paleness, which were signs of ischemia, were not communicated to the physician. The facility's policy required prompt notification of the physician and detailed assessment of any change in a resident's condition. However, the LN did not perform an assessment or notify the physician, leading to a lack of awareness of the resident's deteriorating condition. The director of nurses confirmed that the LN should have taken the VS and assessed the resident before notifying the physician. The director of staff development had conducted training on change of condition documentation, but the LN involved did not attend the in-service.
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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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