Royal Gardens Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Alhambra, California.
- Location
- 2339 W. Valley Blvd., Alhambra, California 91803
- CMS Provider Number
- 055818
- Inspections on file
- 45
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Royal Gardens Healthcare during CMS and state inspections, most recent first.
Surveyors found that two residents did not receive care according to MD orders and facility policy. One resident with severe cognitive impairment and a cervical spine wound had a documented daily wound care order with Dakin’s solution, Betadine, and calcium alginate, but the TAR showed no wound treatments documented over multiple days, and nursing staff acknowledged that new wound orders were not entered or carried out. Another resident with chronic pain conditions and moderate cognitive impairment had MD orders for PRN analgesics and a possible referral to a pain specialist; the resident and a CNA reported ongoing pain and delays in pain medication, and both the SSD and an LVN admitted they did not follow up on the MD order for a pain specialist referral, resulting in no appointment being arranged.
Two residents experienced lapses in infection control when an RN performed wound care on a resident with a sacral stage 4 pressure ulcer and local skin infection without changing gloves or performing hand hygiene after removing a soiled dressing and cleansing the wound, and then left the room after doffing PPE without hand hygiene, contrary to facility policies requiring aseptic technique and hand hygiene after glove and PPE removal. In a separate incident, an RN used the same reusable BP cuff on two residents without disinfecting it between uses, despite facility policy and the DON/IP’s expectation that reusable equipment be cleaned and disinfected between residents.
A resident with muscle weakness, COPD, depression, moderate cognitive impairment, and dependence on staff for most ADLs was observed lying in bed with the call light placed on the top corner of the bed, out of reach, while the resident stated being thirsty and unable to summon help. A CNA confirmed the call light was not within reach and acknowledged it should have been, and the DON stated call lights should always be accessible. Facility policy on answering call lights required that call lights be accessible to residents in bed, on the toilet, in the shower/bath, and from the floor, but this was not followed in this instance.
A resident with Parkinson’s disease, dementia, muscle weakness, difficulty walking, and severe cognitive impairment was identified as high risk for falls and required substantial assistance with most ADLs. Progress notes documented an unwitnessed fall after the resident got up without asking for help, and multiple staff (a CNA, an LVN, and an RN) reported the resident routinely attempted to get up alone, often to have an adult brief changed. Despite this ongoing behavior and a prior fall, the DON confirmed there was no individualized care plan addressing the resident’s unassisted attempts to get up and no revision of the care plan after the fall, contrary to facility policy requiring an IDT-developed, person-centered care plan with measurable objectives and updates for changes in condition.
Two residents experienced significant medication-related deficiencies involving both administration and reconciliation. For one resident with multiple chronic conditions and moderate cognitive impairment, an RN administered seven medications without verifying identity via wrist band or photo and without explaining the medications or their indications, and Eliquis for DVT prophylaxis was not available because it had not been refilled in time. For another resident with psychosis and schizoaffective disorder, the DSD inaccurately transcribed a risperidone order during admission, entering three tablets twice daily instead of one tablet twice daily despite a system alert, which led to the pharmacy not dispensing the drug and the resident not receiving risperidone for several days.
A resident with schizoaffective disorder, depression, anxiety, and severely impaired decision-making, who had documented episodes of physical and verbal aggression such as yelling profanities and throwing or shoving objects, was left briefly unattended in a hallway by the Admission Director while en route to a shower. During this time, a visitor observed the resident screaming at another resident seated in a wheelchair and pushing a laundry cart into that resident, who cried out in pain, while the aggressive resident continued cursing. Staff interviews confirmed the aggressive behavior pattern and that the laundry cart, normally kept at the side of the hallway, was behind the wheelchair at the time of the incident. The DON acknowledged that despite early manifestations of aggression, the resident’s behaviors were not placed on behavior monitoring and that the facility failed to prevent the physical abuse, in violation of its abuse and neglect policy.
A resident with paraplegia, urinary retention, and a right lower abdominal urostomy was allowed to perform self-catheterization without a physician order, competency assessment, or care plan, contrary to facility policy. Staff acknowledged they had never observed or assisted with the resident’s urostomy care and were unaware of the peristomal skin condition. From admission for several days, there was no urostomy care order, no documented assessment of the resident’s ability to self-catheterize, no records of catheterization frequency, and no monitoring or documentation of intake/output, urine characteristics, or stoma/skin condition as required by the facility’s urostomy and self-catheterization P&Ps.
A resident with CKD, anxiety disorder, and COPD, who required substantial assistance with ADLs, reported that a CNA pulled a sheet from under them and threw it on the floor during evening care. The facility’s CGR form for this grievance was left incomplete, with no documented steps of the investigation, no summary of findings or conclusions, and no confirmed decision date. The SSD, DON, and DSD all acknowledged that required investigative elements—such as incident details, involved staff, witness accounts, and interview documentation—were not recorded, and that the CNA involved was initially misidentified, demonstrating a failure to follow the facility’s grievance investigation policy.
A resident with CKD, anxiety disorder, and COPD, who was cognitively intact and dependent for many ADLs, reported that a CNA on the evening shift was mean, pushy, and made the resident cry by roughly yanking a drawsheet, throwing it on the floor, pulling out the resident’s brief, and grabbing and holding the resident’s arm to prevent the resident from fastening the brief tabs. The facility initiated an investigation but failed to follow its abuse investigation policy: the Investigation Report and CNA statement were incomplete, missing the investigator’s name, resident and staff identifiers, dates, times, signatures, and other required details, and key leaders (ADM, DON, DHI, DSD) acknowledged that the investigation process and documentation did not meet the facility’s Abuse Investigation and Reporting requirements.
A resident with CKD, COPD, and anxiety, who needed substantial assistance with ADLs, alleged that a CNA was rough, rude, and verbally abusive during incontinence care, including yanking a drawsheet from under the resident, throwing it on the floor, and holding the resident’s arm up to prevent adjusting brief tabs. An RN supervisor heard loud voices, found both the resident and CNA upset, and was told the drawsheet had been thrown on the floor, but did not report this possible abuse due to being busy. Another CNA was told by the resident that staff had been rude but also failed to report it. The resident later informed Social Services, yet the allegation was still not immediately reported to external authorities as required by facility policy, which mandates reporting alleged abuse within 2 hours, resulting in a failure to timely notify the State Survey Agency, ombudsman, and law enforcement.
A resident with CKD, anxiety disorder, and COPD, who was cognitively intact and dependent for several ADLs, reported that a CNA on the 3 PM–11 PM shift was pushy, yanked a drawsheet from under her and threw it on the floor, pulled out her brief, and roughly held her arm straight up during care, causing her to cry. The facility initiated an investigation, but the DSD did not re-interview the resident after speaking with involved CNAs, and the Investigation Report contained incomplete and inaccurate information about which CNA was allegedly rough. Multiple CNA statements were missing key elements such as dates, interviewer names, and signatures, and the DSD and SSD acknowledged that the abuse investigation and documentation did not comply with the facility’s Abuse Investigation and Reporting and Abuse Prevention Program policies.
A resident with cognitive impairment, hemiparesis after stroke, and oropharyngeal aphagia had an ST evaluation indicating the need for assisted feeding to enhance safe swallow, and care plans addressing aspiration risk and swallowing problems. However, staff did not relay the ST recommendation for feeding assistance to the physician or obtain corresponding orders for an extended period, and did not notify the physician or obtain an order for ST reevaluation after the resident was observed to be able to feed himself without 1:1 assistance. A physician order for 1:1 feeding to prevent aspiration was not in place during the timeframe when these assessments and observations occurred.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident was not adequately prepared for a safe transfer or discharge, as the facility did not ensure the process met the individual's needs and preferences.
Two residents with significant cognitive and physical impairments did not have their wound care treatments accurately documented on the TAR, despite physician orders for daily dressing changes. The responsible nurse confirmed that treatments were performed but not signed for, and the DON acknowledged the documentation lapse, resulting in incomplete medical records.
A resident with diabetes and kidney failure did not receive a recommended Controlled Carbohydrate Diet (CCHO) due to a lack of communication between the Registered Dietitian (RD) and the primary physician. The resident continued on a No Added Salt (NAS) diet, which did not meet their dietary needs. The facility's policy requires physician-prescribed therapeutic diets, but the RD's recommendations were not implemented, placing the resident at risk for uncontrolled blood sugar levels.
A facility failed to maintain a safe and homelike environment for several residents. A resident's room was excessively warm, causing discomfort, while another resident experienced frustration due to a malfunctioning television. Two residents' rooms had a strong odor of urine due to incontinence issues, and a resident's room had a chipping wall trim, posing a potential hazard. Staff acknowledged these issues, which affected the residents' well-being.
The facility failed to implement proper pressure ulcer prevention and treatment measures for three residents. A resident with a history of stage 4 pressure ulcer had a low air loss mattress set incorrectly, risking skin breakdown. Another resident with a history of pressure injuries had an alternating air pressure pad mattress set too firm, potentially causing pressure injuries. A third resident with a stage 3 pressure ulcer reported discomfort from a hard mattress, risking further skin damage. The facility did not adjust mattress settings based on residents' weights, as required by policy.
The facility failed to maintain proper pharmaceutical services, with issues such as ice build-up in the medication freezer, dusty storage room counters, and improper temperature control in the medication storage room. Medications like Valproic Acid and Lidocaine were stored at 83°F, exceeding the recommended range, leading to their disposal to prevent adverse reactions.
The facility failed to label opened food items with use-by dates, risking foodborne illnesses. Observations revealed unlabeled items like butter, chocolate syrup, and hash browns in the kitchen, and No Bake Custard and Gravy Mix in storage. The DS admitted the absence of labels, and the DON and RD confirmed the policy requirement for labeling to ensure food quality and safety.
A long-term care facility failed to follow infection prevention and control practices for several residents. A urine-soaked diaper was found on a paper towel dispenser, and two LVNs did not use required protective equipment while administering medications via gastrostomy tubes. Additionally, a nebulizer mask was found on the floor, and a urinal bottle was placed next to a water pitcher, both posing contamination risks.
A resident with dysphagia and cognitive impairment waited 32 minutes for their meal tray while others at the table were eating. The delay occurred despite meal carts arriving on time, and the resident felt uncomfortable and disrespected. The facility's policy emphasizes providing a dignified dining experience.
The facility failed to ensure call lights were within reach for three residents, violating policy. A resident with cognitive impairment had a call light out of reach, confirmed by a CNA. Another resident with right side weakness had a call light on the wrong side, confirmed by an LVN. A third resident, unable to use fingers, had a call light on the floor, leading to yelling for help. The facility's policy requires accessible call lights.
A resident receiving antibiotic and anticoagulant therapies did not have a comprehensive care plan developed, as required by facility policy. The absence of care plans for Ceftriaxone and Eliquis meant the resident was not monitored for treatment effectiveness or side effects. The MDS Nurse and DON acknowledged the oversight, which was contrary to the facility's care plan policy.
A facility failed to monitor a resident's behavior for the use of psychotropic medications, Abilify and Depakote, as required by their policy. The resident, diagnosed with dementia and schizophrenia, had no documented behavior monitoring orders, and the MAR was blank for a month, indicating a lack of monitoring. This deficiency was identified during interviews and record reviews.
A facility failed to maintain a medication error rate below 5%, resulting in a 10.34% error rate. An LVN administered multivitamin, vitamin C, and vitamin D3 to a resident over an hour past the prescribed time. The resident had severe cognitive impairment and required assistance with daily activities. The facility's policy mandates medication administration within one hour of the prescribed time.
The facility did not post the required Daily Nurse Staffing Information for several days, as observed on 12/2/2024. The Assistant Administrator and Director of Nursing confirmed that the Direct Care Service Hours Per Patient Day (DHPPD) postings were missing, which are essential for informing residents, families, and staff about staffing levels. The facility's policy requires daily posting of nurse staffing data, but this was not followed, leading to a deficiency.
The facility did not meet the minimum 80 square feet per resident requirement in 12 of 17 rooms. Despite this, residents reported adequate space for care and movement, and a room waiver was requested, asserting no impact on health and safety. Observations confirmed adequate ventilation, lighting, and privacy, with sufficient space for wheelchairs and medical equipment.
The facility did not post daily staffing information as required, with outdated and incomplete Census and Direct Care Service Hours Per Patient Day (DHPPD) forms observed. The DON was unaware of the requirement to post completed forms daily, leading to missing postings for several days in September.
Three residents in an LTC facility did not receive consistent treatment for pressure ulcers, as documented in their Treatment Administration Records. A resident with a deep tissue injury and Stage 2 ulcer, another with a Stage 4 ulcer, and a third with an unstageable ulcer all missed prescribed treatments, including zinc oxide application, low air loss mattress therapy, and wound cleaning. Interviews confirmed that blank entries in records indicated treatments were not performed, violating facility policy.
A resident with dementia was physically abused by another resident with psychosis in the activity room of an LTC facility. The incident occurred when the aggressive resident, who had a history of physical altercations, struck the vulnerable resident in the face. Staff interviews confirmed the altercation, and it was noted that no staff were present in the room at the time to prevent the incident, despite the facility's policy to protect residents from abuse.
A facility failed to update a resident's care plan after a physical altercation with another resident. The resident, who has unspecified psychosis and moderately impaired cognitive skills, showed increased agitation and aggression. Despite the incident, the care plan was not revised to include new interventions for the resident's safety and behavior management, contrary to facility policy requiring updates for significant changes in condition.
Failure to Follow Wound Care and Pain Management Specialist Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards for two residents. For one resident with osteomyelitis of the vertebra, intraspinal abscess, and granuloma, the resident’s MDS dated 3/5/2026 showed severe cognitive impairment and dependence or significant assistance needs for most activities of daily living, including transfers, bed mobility, dressing, and personal hygiene. Wound assessment documentation dated 2/10/2026 showed a physician-ordered daily treatment for a cervical spine wound using Dakin’s solution, Betadine, and a calcium alginate dressing. However, review of the Treatment Administration Record (TAR) for February 2026 showed no documented administration of this wound treatment for 10 days (2/8/2026 to 2/16/2026 and 2/18/2026). During interviews, the DON confirmed there was no documentation that the resident received wound care treatment for the cervical spine wound on those 10 days, and stated that treatment should have been done daily per the wound physician’s order. LVN 1, when reviewing the same records, stated that the last physician treatment orders stopped on 2/7/2026 and that no new orders were entered per the wound physician’s order documented in the wound assessment. LVN 1 acknowledged that the cervical spine wound treatment orders should have been followed up and entered into the system to avoid a delay in care or treatment. The DON further stated that no new orders were input for the cervical spine wound treatment from 2/8/2026 to 2/17/2026 and that the resident did not receive wound care treatment during the identified 10 days. Facility policies on pressure ulcers/skin breakdown, wound care treatment, and treatment administration required that wound treatments be performed and documented in accordance with physician orders and professional standards of practice. For a second resident with diagnoses including fibromyalgia, muscle weakness, and osteoarthritis, the MDS indicated moderate cognitive impairment, a need for supervision or touching assistance with toileting, bathing, dressing, and footwear, and that the resident experienced occasional pain that sometimes limited day-to-day activities, with moderate pain reported within the last five days of the assessment. Physician orders dated 1/16/2026 included PRN aspirin, oxycodone, and ibuprofen for varying levels of pain, and an order stating "May refer to Pain Specialist." The resident reported telling the Social Services Director (SSD) and LVN 1 about ongoing pain, stating that the facility would give aspirin for breakthrough pain but that pain persisted, and that LVN 1 told him he would have to wait until the next scheduled oxycodone dose. A CNA reported that when the resident was in pain and this was reported to licensed nurses, the nurses responded that it was not time yet for the resident’s pain medication. The SSD stated that she did not follow up on the physician’s order for a pain specialist and that no appointment was arranged, acknowledging that she should have followed up on the order. LVN 1 stated he did not follow up on the order for the resident to see a pain specialist, explaining that "May see a pain specialist" meant that if the resident’s pain was unmanaged by current medications, the resident could see a pain specialist, and that the facility needed to ensure the resident’s pain was managed. The DON stated that the physician’s order "May see a pain specialist" meant that if the resident was having unmanaged pain, the resident needed to see the pain specialist, and acknowledged that the resident should have been seen by a pain specialist but that this was not followed up or done. Facility policies on pain management and appointments indicated that acceptable pain control is defined by the resident, that pain should be accurately assessed and controlled, and that the facility will help residents contact specialty providers as needed based on health recommendations, with nursing staff informing the unit clerk or designee about appointment orders based on medical necessity.
Failure to Follow Hand Hygiene, Wound Care, and Equipment Disinfection Protocols
Penalty
Summary
The deficiency involves failures in infection prevention and control practices during wound care and vital sign assessment for multiple residents. For one resident with a sacral stage 4 pressure ulcer and local skin infection, an RN performed wound care without changing gloves or performing hand hygiene after removing the dirty dressing and cleaning the wound. The RN removed the resident’s soiled dressing, cleansed the wound, and then immediately applied santyl collagenase ointment, collagen powder, calcium alginate, and a dry dressing without changing gloves or cleaning her hands, despite facility policies requiring hand hygiene and glove change when moving from a soiled to a clean task. The RN later acknowledged she had applied the ointment and powder with a tongue depressor but then directly handled the calcium alginate and dry dressing with the same contaminated gloves. In the same episode of care, after completing the wound treatment in the resident’s room, the RN removed her PPE, discarded it in the trash, and exited the room with the treatment cart without performing hand hygiene. This occurred even though the facility’s hand hygiene and wound care policies required hand hygiene immediately after glove removal, after exposure to wound drainage, and after removing PPE, as well as strict adherence to aseptic technique and avoidance of cross-contamination of supplies. The DON/Infection Preventionist confirmed that staff are expected to change gloves and perform hand hygiene after removing old dressings and cleaning wounds, and to perform hand hygiene upon doffing PPE and leaving a resident’s room. A separate deficiency occurred when another RN failed to disinfect a reusable blood pressure cuff between residents. The RN was observed checking one resident’s blood pressure and administering medications, then shortly afterward using the same blood pressure cuff on another resident without disinfecting it in between uses. During interview, the RN stated she did not disinfect the cuff between residents and acknowledged that the cuff should be disinfected between residents for infection control reasons. The DON/Infection Preventionist stated that equipment should be disinfected before and after each resident, and the facility’s cleaning and disinfection policy specified that reusable items are to be cleaned and disinfected or sterilized between residents.
Failure to Keep Call Light Within Reach of Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in which staff failed to ensure a resident’s call light was within reach while the resident was in bed. The resident had been admitted and later readmitted with diagnoses including muscle weakness, COPD, and depression. According to the MDS dated 3/6/2026, the resident was moderately impaired in cognitive skills for daily decision making and required substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene, and was dependent for toileting hygiene, showering/bathing, lower body dressing, and footwear. During an observation and interview in the resident’s room on 4/15/2026 at 2:53 PM, the resident was found lying in bed with the call light placed on the top right corner of the bed, out of the resident’s reach. The resident stated she was thirsty, needed water, and could not reach the call light to alert staff. In a concurrent observation and interview at 2:55 PM, CNA 2 confirmed that the call light was placed on the top right corner of the bed, acknowledged that it was not within the resident’s reach, and stated that the call light should be within reach so the resident could call staff for assistance. In a subsequent interview on 4/16/2026 at 1:30 PM, the DON stated that the call light should always be within the resident’s reach so the resident can use it when assistance is needed. Review of the facility’s policy and procedure titled “Answering the Call Light,” revised 9/2022, indicated that staff are to ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor. The observed placement of the call light for this resident did not comply with the facility’s policy or the stated expectations of staff and leadership.
Failure to Care Plan for High-Risk Resident’s Unassisted Getting Out of Bed
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to address one resident’s behavior of getting out of bed and up without assistance. The resident had diagnoses including difficulty walking, Parkinson’s disease, muscle weakness, and dementia, and was assessed as being at high risk for falls. The MDS showed the resident was severely impaired in cognitive skills for daily decision-making and required substantial/maximal assistance with most ADLs, and partial/moderate assistance with eating and oral hygiene. Progress notes documented an unwitnessed fall, with notation that the resident did not ask for assistance prior to mobility. Staff interviews confirmed that since admission the resident had a known tendency to get up without assistance, often related to needing an adult brief/diaper change. A CNA, an LVN, and an RN each stated that the resident frequently attempted to get up alone without calling for help. During review of the resident’s care plans over a multi-year period, the DON acknowledged there was no care plan addressing the resident’s behavior of getting up unassisted and no care plan revision after a prior fall, despite the expectation that the care plan be revised with each change in condition. This was inconsistent with the facility’s policy on comprehensive person-centered care plans, which requires the IDT, with the resident and representative, to develop and implement a comprehensive care plan based on assessment findings to describe services needed to attain or maintain the resident’s highest practicable well-being.
Medication Administration and Reconciliation Failures Affecting Two Residents
Penalty
Summary
The deficiency involves failures in pharmaceutical services and medication administration for two residents. For the first resident, who had atrial fibrillation, hemiplegia, hemiparesis following cerebral infarction, and moderate cognitive impairment, the facility did not ensure proper medication administration practices. This resident had multiple physician orders, including Eliquis for DVT prophylaxis, antihypertensives, GI medication, iron supplement, lactulose, calcium with vitamin D, and prednisone. On review of the MAR for the month, several medications, including ferrous sulfate, lactulose, oyster shell calcium + D, and metoprolol tartrate, were documented as refused. The resident stated he refused his medications on one day because the RN did not explain the seven medications being given. During a medication pass observation, RN 2 prepared medications for this resident and stated that the facility was out of Eliquis and needed to request a refill from the pharmacy. RN 2 then administered seven medications without checking the resident’s wrist band or the photograph in the medical record to confirm identity and did not explain the types of medications or their indications. In a subsequent interview, RN 2 acknowledged not explaining the medications or checking the wrist band before administration and confirmed that Eliquis had not been administered because it was not available and had not been refilled on time. The DON stated that nurses are expected to explain medications and indications, verify resident identity using identifiers such as wrist bands, and ensure timely refills so medications are given as ordered. Facility policies on administering medications and resident rights required verification of identity and informing residents about their treatment. For the second resident, who had diagnoses of unspecified psychosis and schizoaffective disorder and was severely cognitively impaired, the deficiency involved inaccurate medication reconciliation on admission. The hospital discharge medication reconciliation listed risperidone 3 mg, one tablet orally twice a day. However, the facility’s order summary, entered by the DSD, showed an order for risperidone 3 mg, three tablets by mouth twice a day for schizophrenia. A physician order note documented that this order, entered on admission, was outside the recommended dose or frequency and exceeded the usual dosing regimen. In interviews, an LVN described the standard admission process of reviewing the admission packet, notifying the MD, obtaining approval to continue medications, and accurately inputting orders, emphasizing the importance of double-checking alerts and reconciling orders to avoid transcription errors. The DSD stated that when admitting this resident, she was tired and transcribed the risperidone order incorrectly as three tablets twice a day instead of one tablet twice a day and did not notice the system alert that the dose was above the recommended range. The DON/IP confirmed that the medication reconciliation for this resident’s risperidone was not accurate and that the incorrect order prevented the pharmacy from dispensing the medication, resulting in the resident not receiving risperidone for three days, which the DON/IP stated could have further aggravated the resident’s condition.
Failure to Prevent Resident-to-Resident Physical Abuse Involving Laundry Cart Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with schizoaffective disorder, depression, anxiety, severely impaired decision-making, and a known history of physical and verbal aggression, including yelling profanities and shoving or throwing objects at others, was not being monitored for aggressive behaviors. A Change in Condition (COC) evaluation documented that this resident had episodes of yelling profanities and shoving objects at other residents, but there were no corresponding physician orders or behavior monitoring in the medical record to address or track these behaviors. On the day of the incident, the Admission Director was escorting this aggressive resident to the shower when the resident became upset about the appearance of the shower. The Admission Director briefly left the resident unattended in the hallway to obtain more towels. During this time, a visitor reported hearing yelling and observed the aggressive resident screaming at another resident who was seated in a wheelchair in the hallway. The visitor stated that the aggressive resident pushed a laundry cart or basket into the wheelchair-bound resident, who then yelled "ouch," and that the aggressive resident continued cursing at the other resident while walking toward the shower. Staff interviews and documentation corroborated that the aggressive resident had a pattern of rude, verbally aggressive, and unsafe behavior toward staff and other residents, including throwing items on the floor and being described as really aggressive and unsafe to others. A nurse heard the wheelchair-bound resident say "ouch" and the aggressive resident shouting profanities in the hallway, and was informed by the visitor that the laundry cart had been pushed into the resident in the wheelchair. The Director of Nursing acknowledged that the aggressive behavior, which began as early as the resident’s second day in the facility, had not been included in behavior monitoring and that the facility failed to prevent the aggressive resident from pushing the laundry cart into the other resident, contrary to the facility’s abuse and neglect policy requiring measures to minimize the possibility of abuse.
Failure to Assess, Order, and Monitor Urostomy and Self-Catheterization Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary urostomy and self-catheterization care and treatment for one resident in accordance with its own policies and procedures. The resident was admitted with diagnoses including urinary retention, paraplegia, and lack of coordination, and had an opening on the right lower abdomen for bladder drainage, using a straight catheter for voiding. The resident’s MDS documented an ostomy appliance, total dependence for toileting and dressing, and urinary incontinence, while cognitive skills for daily decision-making were independent. Despite these conditions, there was no physician order for urostomy care from admission until several days later, and the only order identified was to cleanse the urostomy site with normal saline, pat dry, and leave open to air, starting on a later date. The resident reported performing self-catheterization and primarily using personal supplies, requesting some items such as gauze from staff, but refused to show the stoma or provide details of the procedure. Nursing staff, including an LVN, stated that the resident performed self-catheterization but they had never assisted with or observed the urostomy care and were unaware of the condition of the skin around the stoma. The RN confirmed that urostomy care was not performed from admission until the date the urostomy care order was written, and that there were no physician orders, assessments, or documentation establishing that the resident could safely perform self-catheterization or indicating how often the resident catheterized. Further record review and interviews showed that the facility did not maintain required monitoring and documentation related to the resident’s urostomy and self-catheterization. There were no records of the resident’s intake and output, no documentation of urine output or its characteristics, and no evidence that the skin around the stoma was inspected for irritation or breakdown. The infection prevention nurse confirmed that the resident had not been evaluated for ability to perform self-catheterization, that there was no physician order for self-catheterization, and that no care plan addressing urostomy care and self-catheterization had been developed upon admission, contrary to the facility’s urostomy/ureterostomy care and self-catheterization policies, which require physician orders, competency verification, ongoing monitoring, and documentation of intake/output and peristomal skin condition.
Failure to Properly Investigate and Document Resident Grievance
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance investigation and documentation procedures for a cognitively intact resident who filed a grievance about staff conduct during care. The resident, who had chronic kidney disease, anxiety disorder, and COPD, required substantial to maximal assistance with toileting, bathing, dressing, and transfers. A Complaint and Grievance Report (CGR) form documented that during an evening shift, an unidentified CNA pulled a sheet from under the resident and threw it on the floor during care. The Social Services Director (SSD) received the grievance report later and noted that the resident could not recall the CNA’s name, and the SSD endorsed the report to the Director of Staff Development (DSD) and nursing for follow-up. When surveyors reviewed the CGR form with the SSD, they found that key sections were left blank, including the steps taken to investigate the grievance, the summary of pertinent findings or conclusions, and the date the grievance decision was confirmed. The SSD acknowledged that the nursing department was responsible for follow-up interviews and documentation of the investigation, and that the CGR should have included details such as the in-service topic discussed with the CNA and a summary of the investigation. The SSD further acknowledged that she did not review or follow up on the investigation, did not complete the missing sections, and did not explain to the resident the steps taken to investigate the grievance. Additional interviews with the DON and DSD confirmed that the investigation was incomplete and not documented in accordance with facility policy. The DON stated that the CGR form lacked documentation of the steps taken to investigate and any attached investigation report, and that required elements from the grievance policy—such as date and time of the alleged incident, circumstances, location, names of witnesses and their accounts, and recommendations for corrective action—were not recorded. The DSD similarly stated that the nursing department was responsible for follow-up interviews and documentation, but the CGR form remained incomplete, missing information such as names of staff interviewed, the resident’s name, interview times and dates, and names of involved persons. The SSD later stated that the initial investigation had incorrectly identified the CNA involved, further demonstrating that the grievance investigation process and documentation were not properly carried out for this resident.
Failure to Properly Investigate Resident’s Allegation of Rough and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse investigation policies and procedures after an allegation of verbal and rough physical treatment toward a resident. The resident, who had chronic kidney disease, anxiety disorder, and COPD, was cognitively intact and required substantial to maximal assistance with toileting, bathing, dressing, and transfers. The resident reported that a CNA on the 3 PM–11 PM shift had a bad attitude, was pushy, and was mean, and that this interaction made the resident cry. In interviews, the resident described an incident in which the CNA roughly yanked the drawsheet from under the resident and threw it on the floor near the door, pulled out the resident’s brief, and grabbed and held the resident’s right arm straight up while the resident was attempting to fasten the brief tabs, which the resident typically adjusted independently. The resident stated that this occurred on a Sunday night, that the CNA’s behavior was rough and scary, and that the resident did not like what the CNA did. The resident reported the CNA’s bad attitude to the Social Services Director the following day. Record review showed that the facility’s investigation documentation was incomplete and did not comply with the written Abuse Investigation and Reporting policy. The Investigation Report lacked the name of the investigator, the names of all staff interviewed, the name of the resident involved, and the times of the interviews. The Administrator, DON, DHI, and DSD each acknowledged that the investigation report and CNA statement were missing required elements such as dates, times, resident and staff identifiers, interviewer name, staff phone number, and signatures. The DON and DSD stated that the investigation process outlined in the abuse policy was not followed and that the documentation was inaccurate, incomplete, and not considered a valid investigation report, despite the policy requiring thorough review of documentation, resident interviews, staff interviews on all shifts, and review of events leading up to the alleged incident.
Failure to Timely Report Allegation of Abuse to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse within the required 2‑hour timeframe to the State Survey Agency, state ombudsman, and local law enforcement. A cognitively intact resident with chronic kidney disease, anxiety disorder, and COPD, who required substantial to maximal assistance with several ADLs, alleged that a CNA on the 3 PM to 11 PM shift was rough, pushy, and verbally abusive during incontinence care. The resident reported that the CNA yanked a drawsheet from under her, threw it on the floor near the door, pulled out her brief, grabbed her arm, and held it straight up while changing her, preventing her from adjusting the brief tabs as she preferred. The resident stated the CNA was mean, rough, and scary, and that the interaction made her cry. On the evening of the incident, an RN supervisor heard loud voices from the resident’s room, entered, and observed both the resident and the CNA were upset. The resident told the RN supervisor that the CNA had thrown the drawsheet on the floor and was not listening to her request to have two drawsheets. The resident refused further care from the CNA, and her voice was described as shaky. The RN supervisor acknowledged that she recognized this as a possible allegation of abuse but became overwhelmed and busy with her shift and did not report the incident to the Administrator, DON, or another licensed nurse as required. Another CNA later reported that the resident had told her the CNA who took over her care after 7 PM that Sunday was rude to her, but this CNA also did not report the allegation to supervisory staff. The resident reported the incident to the Social Services Director the following day, describing the CNA’s actions with the drawsheet and her perception that the CNA was rough and rude. The Social Services Director did not immediately conduct a thorough investigation or report the allegation to the appropriate agencies at that time. The facility’s policies on Abuse Investigation and Reporting and Abuse Prevention Program required that alleged violations of abuse, neglect, exploitation, or mistreatment be reported immediately, and not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury. The DON confirmed that CNAs are mandated reporters and that staff should have reported the allegation within two hours, including when the resident told a CNA that staff was mean, which the DON identified as possible verbal abuse. Despite these requirements, the allegation was not reported within the mandated timeframe, resulting in the cited deficiency.
Failure to Thoroughly Investigate Resident’s Allegation of Rough Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse involving one resident, as required by its abuse policies and procedures. The resident, who had chronic kidney disease, anxiety disorder, and COPD, was cognitively intact and required substantial/maximal assistance with several ADLs, including toileting, bathing, dressing, and transfers. During an interview, the resident reported that a CNA on the 3 PM–11 PM shift had a bad attitude, was pushy, yanked out the drawsheet from under her and threw it on the floor near the door, pulled out her brief, and grabbed and held her arm straight up while changing her, which the resident described as mean and causing her to cry. The resident stated she had reported the CNA’s bad attitude to the Social Services Director the day before the survey interview. The facility initiated an investigation documented on an Investigation Report dated 1/20/2026. That report reflected that another CNA stated the resident had told her that the CNA who took over the 3 PM–11 PM shift was rude, and that CNA 2 acknowledged taking over the resident’s care at 7 PM. CNA 2 reported that when she returned to change the resident, she rolled up and pulled out a dirty drawsheet, the resident grabbed and unrolled it, and food crumbs fell back on the bed; CNA 2 then took the drawsheet and left the room to look for the nurse in charge. The report also indicated CNA 2 informed an RN Supervisor that the resident had stated CNA 2 was being rough. However, the Director of Staff Development did not interview the resident after interviewing CNA 2 and CNA 3, explaining that the report was viewed as only involving pulling out the drawsheet and putting it on the floor. Record review and staff interviews showed that the investigation documentation was incomplete and inaccurate. The Social Services Director later acknowledged that the investigation conclusion was not accurate regarding which CNA the resident alleged was rough and that more in-depth follow-up interviews with the resident and involved staff should have been conducted. The DSD identified that CNA statements were incomplete or undated, missing the interviewer’s name, interview date, staff phone number, and staff signature, and stated that one CNA’s statement was not valid due to these omissions. The DSD also confirmed that the facility’s Abuse Prevention Program policy, which requires the investigator to record complete investigation results on approved forms and provide them to the Administrator, was not followed, as the investigation lacked essential information such as date and time, resident and staff involved, and the name of the interviewer/investigator.
Failure to Communicate ST Feeding Recommendations and Obtain Timely Physician Orders
Penalty
Summary
The facility failed to provide necessary care and services in accordance with standards of practice for one resident by not relaying a speech therapist’s recommendation for feeding assistance to the physician and not obtaining corresponding physician orders. The resident had a history of hyperlipidemia, hemiplegia and hemiparesis following a stroke affecting the right dominant side, and oropharyngeal aphagia. An MDS dated 12/10/2025 documented cognitive impairment and a need for staff supervision with eating, as well as partial/moderate assistance for oral and personal hygiene. A speech-language pathology evaluation and plan of treatment dated 11/16/2025 indicated the resident was on three meals with assistance of feeding to enhance safe swallow. However, there was no documented evidence that this recommendation was communicated to the physician or that an order for this assistance was obtained between 11/16/2025 and 12/21/2025. During this same period, from 11/17/2025 to 12/19/2025, the resident was observed and assessed to be able to feed himself without 1:1 assistance, yet the facility did not relay this change in status to the physician or obtain an order for a new ST evaluation to reassess the resident’s feeding needs. Physician orders only reflected a 1:1 feeding requirement to prevent aspiration beginning on 12/22/2025 at 10:56 PM, with no such orders in place from 11/16/2025 to 12/21/2025. The resident’s care plan for risk of aspiration, initiated 11/18/2024 and revised 12/18/2025, directed staff to monitor for signs and symptoms of aspiration, provide prompt intervention, and inform the physician, and a separate care plan for swallowing problems was initiated on 12/4/2025. Despite these care plan directives and the ST evaluation, the facility did not ensure physician notification and appropriate orders regarding feeding assistance and ST reevaluation during the identified timeframe.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Accurately Document Wound Care Treatments
Penalty
Summary
The facility failed to maintain accurate documentation of wound care treatments for two residents, as required by its own policy and accepted professional standards. For one resident with a sacral pressure ulcer and significant physical and cognitive impairments, the Treatment Administration Record (TAR) was left blank and not signed for a scheduled wound care treatment. The physician's order specified daily dressing changes, but the lack of documentation on the TAR for a specific date resulted in an incomplete medical record for the care provided. For a second resident with multiple pressure ulcers at various stages and severe cognitive impairment, the TAR was not signed for several wound care treatments on two separate days. The physician's orders detailed specific wound care procedures for multiple sites, but the TAR lacked the initials of the nurse responsible for administering these treatments. During interviews, the nurse who provided the care confirmed that the treatments were performed but not documented at the time, and the Director of Nursing acknowledged that the TAR should have been signed immediately after care was provided. The facility's policy on charting and documentation requires that all services provided to residents be documented in an objective, complete, and accurate manner, including the date, time, and name of the individual providing care. The failure to document wound care treatments as required resulted in medical records that did not accurately reflect the care provided to the two residents.
Failure to Implement Recommended CCHO Diet for Diabetic Resident
Penalty
Summary
The facility failed to provide a Controlled Carbohydrate Diet (CCHO diet) for a resident with type 2 diabetes mellitus, dementia, and acute kidney failure. The resident was admitted with a diagnosis that required careful management of blood sugar levels. Despite the Registered Dietitian's (RD) recommendation to change the resident's diet to a CCHO diet, this was not communicated to or ordered by the resident's primary physician. The resident continued to receive a No Added Salt (NAS) mechanical soft diet, which did not meet the specific dietary needs for managing diabetes. The deficiency was identified during a review of the resident's care plan and medical records, which showed that the RD's recommendations were not reviewed by licensed nurses or communicated to the primary physician. The resident's Minimum Data Set (MDS) indicated a need for a therapeutic diet, but the current diet order did not reflect the necessary changes. Interviews with the Licensed Vocational Nurse (LVN), Kitchen Supervisor (KS), Registered Nurse (RN), and Director of Nursing (DON) confirmed that the RD's recommendations were not implemented, and the resident's diet card did not indicate the required CCHO diet. The facility's policy and procedure for therapeutic diets require that such diets be prescribed by the attending physician and regularly reviewed by the dietitian, nursing staff, and physician. However, the failure to communicate and implement the RD's dietary recommendations placed the resident at risk for uncontrolled blood sugar levels, which could lead to serious health consequences. The DON acknowledged the importance of providing a CCHO diet for residents with diabetes to prevent potential complications.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents, leading to various deficiencies. Resident 8's room was observed to be excessively warm at 83 degrees Fahrenheit, which was outside the acceptable range of 71 to 81 degrees Fahrenheit. This was confirmed by the Maintenance Supervisor, who acknowledged the discomfort caused by the high temperature and adjusted the thermostat accordingly. Resident 194 experienced frustration due to a malfunctioning television, which was described as hazy and pixelated. This issue was observed during an interview with the resident, who expressed dissatisfaction with the situation. The Licensed Vocational Nurse present agreed that the television should be repaired to alleviate the resident's frustration. Additionally, the facility failed to maintain a clean and sanitary environment for Residents 18 and 28, as both rooms had a strong odor of urine. This was attributed to Resident 18's frequent urinary incontinence, which resulted in urine on the floor. The presence of an air purifier did not sufficiently address the odor, and staff acknowledged the impact on the residents' well-being. Furthermore, Resident 19's room had a chipping wall trim, which was identified as a potential hazard by both the Registered Nurse Supervisor and the Maintenance Supervisor, who recognized the risk of injury to the resident.
Improper Pressure Ulcer Prevention and Treatment Measures
Penalty
Summary
The facility failed to implement appropriate pressure ulcer prevention and treatment measures for three residents, as observed during a survey. Resident 30, who was at risk for skin breakdown due to a history of a stage 4 pressure ulcer, was found to have a low air loss (LAL) mattress set at an incorrect pressure setting of more than 350 mmHg, which was not aligned with the resident's weight of 220 pounds. This setting was too firm and not in accordance with the manufacturer's guidelines, potentially compromising the effectiveness of the mattress in preventing pressure ulcers. Resident 6, who had a history of pressure injuries and was moderately at risk for skin breakdown, was observed with an alternating air pressure pad (APP) mattress set at the maximum firmness level of 5. This setting was not ideal for the resident's weight of 163 pounds and could lead to the development of pressure injuries. The facility's failure to adjust the mattress settings based on the resident's weight was noted as a deficiency. Resident 1, who had a stage 3 pressure ulcer and was moderately at risk for skin breakdown, was found with an LAL mattress set at 250 mmHg, which was not appropriate for the resident's weight of 203 pounds. The resident reported discomfort due to the mattress being too hard, which could exacerbate existing pressure ulcers or cause new ones. The facility's policy required that mattress settings be adjusted according to the resident's weight, but this was not adhered to, leading to the identified deficiencies.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services as per its policy, resulting in several deficiencies related to medication storage. During an observation and interview with the Director of Nursing (DON), it was noted that the medication storage freezer had an ice build-up, which could affect the accurate temperature maintenance for medications stored inside. Additionally, the medication storage room counters and shelves were found to be dusty, indicating a lack of cleanliness and adherence to the facility's policy of maintaining a clean, safe, and sanitary environment. Furthermore, the temperature in the medication storage room was recorded at 83°F, which exceeded the recommended storage temperature range of 68°F-77°F for certain medications. This included one bottle of Valproic Acid, two bottles of 0.9% Sodium Chloride Irrigation, and one bottle of Lidocaine 2% viscous solution. The DON acknowledged that these medications were not stored under proper temperature control and stated that they would be discarded to prevent potential adverse reactions if administered to residents.
Failure to Label Food Items with Use-By Dates
Penalty
Summary
The facility failed to ensure that food items were properly labeled with use-by dates, which is crucial for preventing foodborne illnesses. During an observation in the kitchen, several opened food items, including a container of butter, a gallon of chocolate syrup, a bag of potatoes hash brown, and 20 tomatoes, were found without labels indicating their use-by dates. The Dietary Supervisor (DS) acknowledged the absence of labels and emphasized the importance of labeling to prevent the use of expired food, which could lead to stomach illnesses among residents. Further inspection in the dry storage room revealed additional items, such as packets of No Bake Custard and bags of biscuit Gravy Mix, also lacking use-by and expiration dates. The DS admitted that the original packaging, which contained the expiration dates, had been discarded, making it impossible to determine the freshness of these items. Interviews with the Director of Nursing (DON) and a Registered Dietary (RD) confirmed that the facility's policy required all opened food items to be labeled with open and use-by dates to maintain food quality and prevent foodborne illnesses.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to standard infection prevention and control practices for four out of fifteen sampled residents. In one instance, a urine-soaked diaper was observed on top of a paper towel dispenser in a communal bathroom, which was acknowledged by the Infection Prevention Nurse as a potential health risk. The Director of Nursing confirmed that such practices could lead to infections and hospitalizations for residents. Additionally, two Licensed Vocational Nurses (LVNs) did not follow Enhanced Barrier Precautions (EBP) while administering medications via gastrostomy tubes to residents who required such precautions. LVN 1 was observed not wearing gloves or an isolation gown while administering medication to a resident with severe cognitive impairment and multiple health issues, including hemiplegia and dysphagia. Similarly, LVN 2 did not wear an isolation gown while administering medication to another resident with severe cognitive impairment and dehydration. The absence of EBP signage and PPE outside the resident's room was also noted. Further deficiencies included a nebulizer mask found on the floor in a resident's room, which was identified as an infection control issue by LVN 5. Another resident's bedside urinal bottle filled with urine was repeatedly observed placed next to the resident's water pitcher, posing a contamination risk. The Registered Nurse Supervisor confirmed that such practices violated the facility's policy to maintain a clean and sanitary environment to prevent infections.
Resident Waits 32 Minutes for Meal Tray
Penalty
Summary
The facility staff failed to ensure a resident received their meal tray in a timely manner, resulting in the resident waiting for 32 minutes while other residents at the same table were already eating. This incident involved a resident who was admitted with diagnoses including dysphagia following a stroke and type II diabetes mellitus. The resident was cognitively impaired and dependent on assistance for eating, as indicated in their Minimum Data Set. During a dining observation, it was noted that the resident was left waiting for their meal tray, which was only provided 24 minutes after other residents had started eating. Interviews with staff and the resident revealed that the meal carts arrived on time, but the resident was not served promptly. The Activity Specialist confirmed the delay and was unsure why the resident was not assisted sooner. The resident expressed feelings of discomfort and disrespect due to the delay. The facility's administrator acknowledged that it was unacceptable for residents to wait longer than five minutes for their meals and emphasized the importance of treating residents with respect. The facility's policy on dignity, revised in February 2021, mandates that residents should be provided with a dignified dining experience, promoting their well-being and self-esteem.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for three residents, which is a violation of the facility's policy and procedure. Resident 1, who has moderately impaired cognitive skills and is dependent on assistance for various activities, was observed with a call light placed out of reach on the left upper side of the bed. This was confirmed during an interview with a Certified Nurse Assistant, who acknowledged that the call light should be within the resident's reach to enable them to call for help when needed. Resident 6, who has severely impaired cognitive skills and is dependent on assistance for daily activities, was observed with a call light placed on the right side, despite having right side weakness and a contracted right hand. A Licensed Vocational Nurse confirmed that the call light should have been placed on the left side, as the resident could not reach it with their left hand. This oversight prevented the resident from being able to call for assistance. Resident 5, who has intact cognitive skills but is dependent on assistance for daily activities, was observed with a call light on the floor, out of reach. The resident, who cannot move their fingers, stated they would call for help by yelling, which was confirmed by their roommate. A Licensed Vocational Nurse later noted that the call button was changed to a call pad that the resident could use effectively, as the previous setup was inappropriate. The facility's policy and procedure require that call lights be accessible to residents, which was not adhered to in these cases.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 22, who was receiving antibiotic and anticoagulant therapies. Upon review, it was found that the care plan did not include specific interventions for the use of Ceftriaxone, an antibiotic, and Eliquis, an anticoagulant. The MDS Nurse acknowledged that the care plan should have been established during the resident's admission, as the resident was already on antibiotic therapy. The absence of these care plans meant that the resident was not being monitored for the effectiveness of the treatments or for potential side effects, such as bleeding from the anticoagulant therapy. Resident 22 was admitted with diagnoses including osteomyelitis, congestive heart failure, and hypertension. The resident required partial to moderate assistance with various activities of daily living. The Director of Nursing confirmed that care plans should be initiated by the admitting nurse and completed by the Registered Nurse or Quality Assurance Nurse. The facility's policy indicated that comprehensive care plans should be developed within seven days of the MDS assessment and no more than 21 days after admission. However, this was not adhered to, resulting in a lack of monitoring for the resident's therapeutic treatments.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drug use, as required by their policy and procedure. The resident, who had diagnoses including dementia, schizophrenia, and hypertension, was prescribed Abilify and Depakote for schizophrenia and bipolar disorder, respectively. However, there was no documented evidence that the resident's behavior was monitored for the use of these medications. The Minimum Data Set (MDS) indicated that the resident had severely impaired cognitive skills and required substantial assistance with daily activities, but did not show any mood or behavior indicators. During interviews and record reviews, it was revealed that there were no physician's orders for behavior monitoring specifically for the use of Abilify and Depakote. The Medication Administration Record (MAR) was blank for the entire month of November, indicating that the resident's behavior was not monitored for the use of these medications. The facility's policy required documentation of targeted behaviors and potential interventions, but this was not done, leading to a deficiency in the care provided to the resident.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 10.34% during a medication administration observation. This deficiency was identified when a Licensed Vocational Nurse (LVN) did not administer multivitamin, vitamin C, and vitamin D3 to a resident within the prescribed one-hour timeframe. The medications were supposed to be given at 9 AM, but were administered at 10:34 AM, exceeding the allowed time window. This practice was not in accordance with the facility's policy, which mandates that medications be administered within one hour of the prescribed time unless otherwise specified. The resident involved, identified as Resident 29, had a medical history that included mild protein calorie malnutrition, metabolic encephalopathy, and type 2 diabetes mellitus. The resident also had severe cognitive impairment and required varying levels of assistance with daily activities. During the medication pass observation, the resident was waiting for their medications, which were administered late by LVN 2. The Director of Nurses confirmed that medications should be given within the specified timeframe to prevent potential adverse effects.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the Daily Posted Nurse Staffing information for the dates 11/29/2024, 11/30/2024, and 12/1/2024, as required by their policy. During an observation on 12/2/2024, it was noted that the staffing posting area only contained forms dated 11/28/2024 and 11/29/2024, with the latter only showing projected hours rather than actual hours worked by nursing staff. Interviews with the Assistant Administrator (AADM) and Director of Nursing (DON) confirmed that the required Direct Care Service Hours Per Patient Day (DHPPD) postings were missing for the specified dates, and the purpose of these postings is to ensure transparency about staffing levels to residents, families, and staff. The facility's policy, revised in 8/2022, mandates that nurse staffing data be posted daily for each shift, including the number of nursing personnel responsible for direct care. This information should be computed and posted within two hours of each shift's start by the charge nurse or designee. The policy also requires that staffing information be maintained for 24 hours in a designated location and then filed as a permanent record for at least eighteen months. The failure to adhere to this policy resulted in a deficiency, as it potentially left residents and visitors uninformed about the facility's staffing levels.
Facility Fails to Meet Minimum Space Requirements in Resident Rooms
Penalty
Summary
The facility failed to provide the minimum required 80 square feet per resident in multiple resident bedrooms for 12 out of 17 rooms. This deficiency was identified during a facility tour and confirmed through interviews and record reviews. The rooms in question were Rooms 101, 102, 104, 106, 109, 110, 111, 112, 114, 115, 116, and 117. Despite the deficiency, residents reported having enough space for care and storage, and those using wheelchairs stated they could maneuver without difficulty. The Assistant Administrator acknowledged the deficiency and indicated that a room waiver was requested, asserting that the deficiency did not impact residents' health and safety. The facility's room waiver letter detailed the square footage per bed for each room, confirming that the space provided was below the required standard. Observations from 12/02/2024 to 12/05/2024 noted adequate ventilation, lighting, and privacy in the rooms, with sufficient space for residents' movement and care provision. The waiver request emphasized that the rooms accommodated wheelchairs and medical equipment, and did not adversely affect residents' health or safety. The Department recommended the room waiver for the affected rooms, acknowledging the facility's efforts to maintain a safe and functional environment despite the space deficiency.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted daily in a visible and prominent place, as required. During an observation on September 30, 2024, the Census and Direct Care Service Hours Per Patient Day (DHPPD) form near the nursing station was found to be outdated, displaying the date September 27, 2024, with the section for Actual Direct Care Service Hours and DHPPD left blank. Further investigation revealed that no DHPPD forms were posted for several dates in September, including the 26th, 28th, and 29th. The Director of Nursing (DON) admitted to being unaware that the completed form with actual hours needed to be posted daily, as per the facility's policy and procedure titled 'Posting Direct Care Daily Staffing Numbers' dated July 2016.
Inconsistent Pressure Ulcer Care in LTC Facility
Penalty
Summary
The facility failed to provide consistent treatment for pressure ulcers for three residents, leading to a deficiency in care. Resident 1, who was readmitted with a deep tissue injury and a Stage 2 pressure ulcer, did not receive the prescribed treatments consistently. The Treatment Administration Record (TAR) lacked documentation of zinc oxide application, low air loss mattress usage, heel offloading, and cleansing with normal saline on several occasions, indicating that these treatments were not administered as ordered. Resident 2, admitted with a Stage 4 pressure ulcer, also did not receive consistent care. The TAR showed missing documentation for cleaning with normal saline, barrier cream application, and dry dressing on specific dates. Additionally, the low air loss mattress therapy and monitoring for leaks and settings were not documented, suggesting these treatments were not performed as required. Resident 3, with an unstageable pressure ulcer, experienced similar issues. The TAR lacked entries for cleaning with normal saline, applying barrier cream, and using a dry dressing. Monitoring of the low air loss mattress for leaks and settings was also not documented on several shifts. Interviews with the treatment nurse confirmed that blank entries in the TAR indicated treatments were not provided, which is against the facility's policy for documenting care.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect Resident 1 from physical abuse when Resident 2 struck them in the face. Resident 1, who was readmitted to the facility with diagnoses including difficulty in walking, type 2 diabetes mellitus, dementia, and chronic kidney disease, was in the activity room when the incident occurred. Resident 1's Minimum Data Set indicated severely impaired cognitive skills and required assistance with daily activities. On the day of the incident, Resident 1 was subjected to physical aggression from Resident 2, resulting in a care plan to prevent further injuries and emotional distress. Resident 2, who was also readmitted to the facility with diagnoses including unspecified psychosis, GERD, and essential hypertension, was involved in the altercation. Resident 2's records indicated moderately impaired cognitive skills and a history of physical altercations. On the day of the incident, Resident 2 exhibited increased agitation and aggression, leading to the physical altercation with Resident 1. The facility's records showed that Resident 2 had a care plan to prevent physical altercations and was under staff supervision for signs of danger to self or others. Interviews with facility staff, including the Director of Nursing, Infection Preventionist Nurse, Assistant Activities Director, and Registered Nurse Supervisor, confirmed the altercation between the two residents. Staff members witnessed Resident 2's aggressive behavior and the subsequent physical contact with Resident 1. The facility's policy on abuse prevention emphasized the residents' right to be free from abuse and the facility's responsibility to protect them from such incidents. However, at the time of the incident, there was no staff present in the activity room to prevent the altercation.
Failure to Revise Care Plan After Resident Altercation
Penalty
Summary
The facility failed to revise the care plan for a resident following a physical altercation with another resident. The care plan, which is intended to provide personalized care with measurable objectives and timeframes, was not updated to include specific interventions for the resident's care and safety after the incident. This oversight was identified during a review of the resident's records and an interview with the Registered Nurse Supervisor, who acknowledged that the care plan should have included new interventions and goals to address the resident's behavior and prevent future incidents. The resident involved in the incident was readmitted to the facility with diagnoses including unspecified psychosis, GERD, and essential hypertension. The resident had moderately impaired cognitive skills and required assistance with daily activities. Following the altercation, the facility's protocol was to notify authorities, but no new interventions were added to the care plan to manage the resident's increased agitation and aggression. The facility's policies require care plans to be revised when there is a significant change in a resident's condition, but this was not done in this case.
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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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