Royal Terrace Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Duarte, California.
- Location
- 1340 Highland Ave., Duarte, California 91010
- CMS Provider Number
- 055541
- Inspections on file
- 32
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Royal Terrace Healthcare during CMS and state inspections, most recent first.
The facility did not have a full-time RN serving as DON for an extended period, instead relying on RN consultants who visited part-time and floor RNs/LVNs to provide oversight. This was contrary to facility policy, which requires a full-time DON to oversee nursing services and ensure regulatory compliance.
Two residents were not adequately protected from accident hazards when a bed sensor alarm failed to alert staff as one resident got up unassisted, and another resident experienced multiple falls with head injuries due to inaccurate or missing fall risk assessments and lack of updated care plan interventions by the IDT.
A resident with severe dementia and psychosis, known for hypersexual and inappropriate public behavior, was placed in a shared room and engaged in indecent exposure and masturbation in front of another resident. Despite the affected resident expressing fear and discomfort to nursing staff, the only response was to advise use of the call light, and the incident was not reported or investigated as required by facility policy. Staff were aware of the ongoing behavior but did not take adequate steps to protect the resident or follow abuse reporting protocols.
A resident with dementia and psychosis repeatedly exposed himself and engaged in inappropriate sexual behavior in the presence of another resident who required substantial assistance with daily activities. Despite staff awareness of the ongoing behavior, it was not reported as sexual abuse to the administrator or authorities, as required by facility policy. Staff later acknowledged the failure to recognize and report the incidents appropriately.
A resident with severe dementia and psychosis exhibited inappropriate sexual behaviors, including exposing himself and masturbating in the presence of another resident and in the hallway. Although staff were aware of and reported the behavior, no care plan was developed to address or manage it, and the affected resident reported feeling unsafe. Facility policy required care planning for significant behavioral changes, but this was not followed.
A resident with multiple chronic conditions expressed a desire to leave the facility but did not receive a new elopement risk assessment or increased supervision as required by policy. After the resident verbalized wanting to leave, staff did not implement additional monitoring or interventions, resulting in the resident leaving the facility unsupervised.
The facility did not ensure that two residents had properly completed and accessible Advance Directives and Acknowledgement Forms in their medical records, despite both having significant medical conditions and cognitive impairments. Staff interviews and record reviews confirmed that required documentation was either missing or incomplete, contrary to facility policy.
Surveyors found that kitchen staff failed to label and date leftover food from outside the facility stored in the refrigerator, and did not label or discard expired items in the dry storage area. The Dietary Supervisor and Lead Cook confirmed these practices were not in line with facility policy, which requires all food to be labeled with delivery, opened, and used by dates, and prohibits storage of outside food in the kitchen.
A resident with a G-tube and severe cognitive impairment was exposed when a staff member checked the G-tube site without closing the privacy curtain, leaving the resident's abdomen and lower extremities visible to others. Both the DSD and DON acknowledged that privacy should have been maintained during care, in accordance with facility policy.
A resident with muscle weakness and contractures was unable to reach the call light, which was found behind the resident and out of reach while in bed. Staff confirmed the call light should have been accessible, and facility policy required it to be within reach. This failure had the potential to delay assistance for the resident.
A resident admitted with cirrhosis, hepatic encephalopathy, and CHF was placed on hospice care, but neither the hospice provider nor facility staff developed or initiated a coordinated hospice care plan as required. Interviews with the SSD and DON confirmed that a comprehensive, individualized plan was not created, despite facility policy mandating such collaboration.
A resident with a Stage 4 sacral pressure ulcer and morbid obesity was found lying on a low air loss (LAL) mattress that was not set according to their actual weight, as required by the care plan, physician orders, and the manufacturer's instructions. Staff confirmed the mattress was set incorrectly, and the resident reported a change in bed firmness. The deficiency was identified through observation, record review, and staff and resident interviews.
A resident dependent on hemodialysis, with end stage renal disease and moderately impaired cognition, did not have a required dialysis emergency kit (E-kit) at the bedside. Observation and staff interviews confirmed the absence of the E-kit, despite facility policy and the resident's care plan specifying its necessity for immediate intervention in case of bleeding from the dialysis access site.
A resident with rib fractures and intact cognition was assessed with severe pain, but a nurse administered Dilaudid as ordered for moderate pain instead of notifying the physician for appropriate orders. Facility policy required medications to be given per prescriber orders, and the DON confirmed the parameters were not followed, resulting in a medication error.
Surveyors found that the medication refrigerator was not consistently maintained within the required temperature range of 36 to 46°F, with temperature logs showing readings both above and below this range. Staff, including an LVN and the DON, confirmed the importance of proper temperature control for medication efficacy, and facility policy also required daily monitoring and adjustment.
Two resident rooms were found to have less than the required 80 square feet per resident, with each room measuring 156 square feet and housing two beds. Staff reported that care could be provided safely and residents had adequate space for mobility and equipment use, and no concerns were raised by residents regarding room size. The facility had requested a waiver for these rooms, and no changes to occupancy were made.
The facility failed to properly handle Advance Directives for two residents, risking treatment against their wishes. One resident's AD was not screened or documented upon admission, while another's AD Acknowledgement form was incomplete. The Social Service Director and Director of Nursing confirmed these oversights, which contradict the facility's policy.
The facility failed to manage and label IV lines appropriately for three residents, leading to potential infection risks. A resident's PICC line port was left uncapped, another's peripheral IV site was unlabeled, and a third's PICC line dressing lacked date labeling. These actions were contrary to the facility's policies, as confirmed by staff interviews.
The facility failed to provide necessary respiratory care and services for four residents receiving oxygen therapy, as per the facility's Policy and Procedure on Respiratory Therapy - Prevention of Infection. A resident was observed not using oxygen, with the oxygen tubing found on the floor. Another resident was using oxygen therapy without the oxygen tubing and humidifier bottle being labeled with the date of change. A third resident used a facemask for breathing therapy that was not labeled with the date of use. Additionally, a fourth resident had oxygen tubing touching a trash bin, which was identified as a contamination risk.
A facility failed to create an individualized care plan for a resident with chronic cystitis, who was prescribed Bactrim. Despite the resident's moderate cognitive impairment and dependency on staff for daily activities, no care plan was documented to guide treatment. This deficiency was confirmed by the RN Supervisor and DON, who acknowledged the oversight in care planning.
A facility failed to perform a smoking assessment for a newly admitted resident with a history of smoking, as required by their policy. The resident, who had acute respiratory failure and hypertension, was observed smoking in the designated area without prior assessment. An LVN confirmed the oversight, highlighting a deficiency in adhering to the facility's smoking policy.
A resident with hemiplegia and hemiparesis required a plate guard and supervision during meals. Despite orders and care plans indicating the need for assistance, the resident was observed eating alone with the plate guard improperly positioned, leading to food spillage. Interviews confirmed the need for proper supervision and positioning to maintain the resident's independence and nutritional status.
A resident's POLST inaccurately indicated the presence of an Advance Directive, leading to potential miscommunication among healthcare providers. The Social Service Director admitted to incorrect documentation, which could result in inconsistent care during emergencies. The resident required substantial assistance and had diagnoses of hydrocephalus and hypertension.
The facility failed to meet the required square footage per resident in two rooms, each housing two residents, which were found to be 156 square feet instead of the required 160 square feet. Despite this, residents were able to move freely, and staff had enough space to provide care. The Administrator acknowledged the issue and planned to submit a room waiver request.
The facility failed to accommodate a resident's needs by not ensuring timely responses to call lights, not assisting with ADLs as per the care plan, and leaving the resident soiled in urine for prolonged periods. Staffing shortages led to delays in care and unmet needs.
The facility failed to implement individualized care plans for six residents, including not performing prescribed ROM exercises and not applying a left elbow splint, potentially diminishing their quality of life.
The facility failed to provide restorative nursing services as ordered by the physician for six residents, leading to potential declines in their range of motion and mobility. Staffing shortages caused RNAs to be reassigned to CNA duties, resulting in missed RNA services for multiple days in April 2024.
The facility failed to ensure sufficient nursing staff, resulting in unmet resident needs and inconsistent RNA services. Multiple residents did not receive timely care or physician-ordered RNA services due to staffing shortages and inadequate responses from the Director of Staff Development.
The facility failed to verify the competencies and skill sets of the nursing staff, leading to several deficiencies, including expired CNA certifications, lack of Skills Competency tests for newly hired CNAs, and missing CPR/BLS certifications. Additionally, the facility did not address staffing shortages, affecting the quality of care provided to residents.
Failure to Designate Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis, as required, from December 9, 2025, to December 23, 2025. During this period, there was no RN working as a full-time DON, despite a census of 52 residents. Observations on December 22 and 23, 2025, confirmed the absence of a designated full-time DON. Interviews with the former DON, the Administrator, and several RNs revealed that the previous DON had resigned in early December, and since then, no RN had been assigned to the full-time DON role. Instead, oversight was provided by RN consultants who visited the facility only 8 to 24 hours per week, and floor RNs and LVNs were considered to be acting as DONs in their absence. Facility policy and job descriptions reviewed during the survey indicated that the DON must be a state-licensed RN with experience in nursing service administration and must be employed full-time (40 hours per week). The policies also specified that RNs report to the DON, and the DON is responsible for overseeing nursing services and ensuring compliance with regulations. Despite these requirements, the facility did not have a full-time DON in place during the specified period, as confirmed by staff interviews and policy review.
Failure to Prevent Accidents and Inadequate Fall Risk Management
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. For one resident with a history of falls, dementia, and impaired cognition, a physician order required the use of a bed sensor pad alarm for safety. However, during observation, the resident was able to get up from bed and walk unassisted to the bathroom without the alarm sounding or staff responding. The resident reported multiple prior falls and stated she was not supposed to walk alone, but did so because staff did not always respond promptly when she needed to use the toilet. Another resident, admitted with diagnoses including metabolic encephalopathy and seizures, experienced multiple falls resulting in head lacerations. Documentation showed that after each fall, the facility's licensed nursing staff either failed to conduct a fall risk assessment or completed it inaccurately, incorrectly assessing the resident as low risk despite repeated incidents. The Director of Nursing confirmed that required fall risk evaluations were not completed or were inaccurate, and acknowledged that this increased the likelihood of further falls. Additionally, the facility's Interdisciplinary Team did not conduct comprehensive root cause analyses following the resident's falls, nor did they update the resident's care plan interventions to address the ongoing risk. The care plan was not reviewed or revised after repeated falls, and the team did not consider the resident's diagnoses as contributing factors. The facility's own policy required post-fall management, including care plan updates and multidisciplinary review, but these steps were not followed after the incidents.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Response to Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in one resident being subjected to indecent exposure by another resident. Specifically, a resident with severe dementia, psychosis, and a history of bizarre and hypersexual behavior, including public masturbation and exposing himself in hallways, was placed in a shared room. Despite staff being aware of this resident's ongoing inappropriate sexual behavior, including an incident where he masturbated in the presence of his roommate, the facility did not take adequate measures to prevent further exposure or ensure the safety of the roommate. The affected roommate, who had a history of acute subdural hemorrhage and mobility difficulties but was cognitively intact, reported feeling unsafe and unable to sleep due to fear of what might happen. The roommate communicated his discomfort and concerns to nursing staff, who only advised him to use the call light if something happened, rather than taking immediate protective action or removing him from the situation. Staff interviews confirmed that the inappropriate behavior was known and had been reported to the previous DON, but the behavior was attributed to the resident's dementia and not recognized as sexual abuse. Facility policy required prompt reporting and thorough investigation of all abuse allegations, but the incident was not reported to the administrator as required. Staff interviews indicated a lack of clarity regarding which residents were exposed and whether the situation was safe, with one RN supervisor acknowledging that it was not safe for the roommate to be alone with the resident exhibiting inappropriate sexual behavior. The facility's failure to act on known risks and to follow abuse reporting protocols resulted in a resident being subjected to sexual abuse and feeling unsafe in his living environment.
Failure to Report and Supervise Sexual Abuse Incidents
Penalty
Summary
The facility failed to ensure residents' right to be free from sexual abuse, specifically in the case involving one resident with a history of dementia, psychosis, and hypersexual behavior. This resident was observed exposing himself and masturbating in the presence of another resident, despite prior knowledge by staff of similar inappropriate behavior occurring in the hallways. Staff interviews and record reviews revealed that the behavior was ongoing, with nursing staff noting repeated incidents and acknowledging that the resident would only stop the behavior when prompted. The staff associated the behavior with the resident's dementia but did not recognize or report it as sexual abuse at the time. The incident involved another resident who required significant assistance with daily activities and had the capacity to understand and make medical decisions. The facility's policy required prompt reporting and investigation of abuse, but the RN Supervisor only reported the behavior to the previous DON and not to the administrator or external authorities. The staff later acknowledged that the behavior constituted sexual abuse and should have been reported according to policy, but this was not done at the time of the incidents.
Failure to Initiate Care Plan for Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to initiate a care plan for a resident who exhibited inappropriate sexual behaviors, including exposing himself and masturbating in the presence of another resident and in the hallway. The resident had a history of severe dementia with psychotic disturbance, unspecified psychosis, depression, and delirium, and was admitted to the facility following psychiatric evaluation for bizarre behavior and significant cognitive impairment. Despite these behaviors being observed and reported by nursing staff, no care plan was developed to address or manage the resident's hypersexual behavior. Interviews with staff revealed that the inappropriate behavior was known to the nursing team, and it was reported to the previous Director of Nursing. Staff acknowledged the behavior as related to the resident's dementia diagnosis but did not consider it sexual abuse. The affected resident who witnessed the behavior reported feeling uncomfortable and unsafe, and communicated these concerns to the nursing staff, who advised using the call light if further incidents occurred. However, there was no evidence in the medical record that a care plan was initiated to address the behavior or to protect other residents. Facility policies required that significant changes in a resident's condition, including behavioral changes, be assessed and addressed through interdisciplinary care planning. The policies also specified that such changes should be documented and that a comprehensive assessment should be conducted. Despite these requirements, the facility did not develop or implement a care plan for the resident's inappropriate sexual behavior, resulting in a deficiency related to the failure to meet the resident's needs and ensure the safety and well-being of other residents.
Failure to Reassess and Intervene After Resident Expressed Intent to Leave
Penalty
Summary
A deficiency occurred when a resident, admitted with diagnoses including cirrhosis of the liver, chronic congestive heart failure, and hepatic encephalopathy, expressed a desire to leave the facility but did not receive appropriate interventions for elopement risk. The resident had previously been assessed as not at risk for elopement upon admission, with the initial evaluation indicating no verbalization of wanting to leave. However, on the day of the incident, the resident told RN 1 that he wanted to leave and go to a friend's house but was unable to provide an address. Despite this verbalization, RN 1 did not complete a new elopement risk evaluation as required by facility policy, nor were additional monitoring or interventions implemented. Subsequently, the resident was discovered missing from the facility, prompting staff to search both inside and outside the premises and in the surrounding community. The Director of Nursing confirmed that the facility's policy required a new elopement risk assessment and closer monitoring when a resident verbalizes intent to leave. The failure to reassess and implement interventions after the resident expressed a desire to leave resulted in the resident leaving the facility unsupervised.
Failure to Complete and Maintain Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that Advance Directives (AD) and AD Acknowledgement Forms were properly completed and included in the medical records for two residents. For one resident with end stage renal disease, hydronephrosis, and dependence on hemodialysis, there was no copy of an AD or AD acknowledgement form in either the paper chart or electronic medical record. The Social Services Director confirmed that these documents should be updated and accessible with each admission or readmission to inform staff of the resident's wishes and preferences. The Director of Nursing also stated that all residents should have updated AD and ADA forms in their records, completed and signed upon admission or readmission, to ensure residents and their representatives are informed of their rights regarding medical treatment and advance directives. Another resident, admitted with type 2 diabetes mellitus and unspecified dementia, had an AD Acknowledgement Form that was not filled out completely. The Social Worker and Director of Nursing both confirmed that the form was incomplete and emphasized the importance of having it fully and accurately completed to reflect the resident's medical wishes. The facility's policy and procedure required inquiry about advance directives and provision of written information about the right to refuse or accept treatment prior to or upon admission, but this was not followed for the sampled residents.
Deficient Food Storage and Labeling Practices in Kitchen and Dry Storage
Penalty
Summary
Surveyors observed that the facility failed to maintain safe and sanitary food storage practices in the kitchen. Specifically, leftover food from outside the facility, including beef, chicken, macaroni salad, and rice, was found in the kitchen refrigerator in unmarked to-go boxes. These items were not labeled or dated and were stored alongside food intended for residents. The Lead Cook confirmed that all food items in the kitchen refrigerator should be labeled with the date received, opened, and used by date, and that food from outside the facility should not be stored in the kitchen refrigerator for infection control purposes. Further observations in the dry storage area revealed multiple food items, such as an open box of chocolate powder, unopened boxes of thickened lemon-flavored water, a bag of hotdog buns, and cans of chocolate pudding, that were not labeled with delivery, opened, or used by dates. Additionally, an opened gallon of teriyaki sauce with a use-by date that had already passed was found on the rack. The Dietary Supervisor acknowledged that all food items should be properly labeled and expired items discarded, in accordance with facility policy. Review of facility policies confirmed requirements for labeling, dating, and discarding expired or partially eaten food, which were not followed in these instances.
Failure to Provide Privacy During G-Tube Care
Penalty
Summary
Staff failed to provide privacy for a resident with a gastrostomy tube during a care procedure. During an observation, the Director of Staff Development (DSD) entered the resident's room and pulled up the resident's gown to check the G-tube site without closing the privacy curtain. This action exposed the resident's abdominal area and lower extremities to both the roommate and the hallway. The resident was noted to have severely impaired cognition and was dependent on staff for all activities of daily living, including personal hygiene and dressing. Interviews with the DSD and the Director of Nursing (DON) confirmed that the privacy curtain should have been closed during care and activities of daily living to maintain the resident's dignity and privacy. The facility's policy on dignity and quality of life also required staff to promote and protect resident privacy during personal care and treatment procedures. The failure to close the privacy curtain resulted in unnecessary exposure of the resident's body during a medical check.
Call Light Inaccessible to Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a call light was within reach and appropriate to the physical abilities of a resident with significant mobility limitations. The resident, who had muscle weakness and contractures affecting both hips, both knees, and the left elbow, was found lying on his left side and unable to locate or reach his call light. A CNA confirmed that the call light was positioned behind the resident's right backside, making it inaccessible, and handed it to the resident. The resident stated he was unable to reach the call light on his own. The resident's care plan and occupational therapy evaluation documented limited mobility, decreased strength, and the need for assistance with activities of daily living. Interviews with staff, including an LVN and the DON, confirmed that the call light should have been within the resident's reach to allow for timely assistance. The facility's policy also required that the call light be accessible to residents when in bed. The failure to ensure the call light was within reach had the potential to delay meeting the resident's needs for assistance.
Failure to Develop Comprehensive Hospice Care Plan
Penalty
Summary
The facility failed to develop an individualized and comprehensive hospice plan of care for a resident who was admitted with diagnoses including cirrhosis, hepatic encephalopathy, and congestive heart failure. The resident was admitted to hospice care upon entry to the facility, as indicated in the Order Summary Report. However, upon review of both the hospice medical record and the facility's electronic medical record, it was found that no hospice care plan had been developed or initiated by either the hospice provider or the facility. Interviews with the Social Services Director and the Director of Nursing confirmed that a coordinated hospice care plan should have been created upon admission to address the resident's specific needs, goals, and interventions. The facility's policy and procedures also require collaboration between facility staff and the hospice agency to establish a care plan based on the resident's assessment. Despite these requirements, the necessary hospice care plan was not in place for the resident.
Failure to Set Low Air Loss Mattress According to Resident Weight
Penalty
Summary
The facility failed to ensure that a low air loss (LAL) mattress was set up accurately according to the manufacturer's instructions for a resident with a history of a Stage 4 sacral pressure ulcer and morbid obesity. The resident's care plan and physician orders specified that the LAL mattress settings should be adjusted based on the resident's weight and personal preference. However, during observation, the mattress was found to be set at a weight setting between 350 lbs to firm, while the resident's actual weight was 144 lbs. Multiple staff members, including the Director of Staff and Development and the Infection Prevention Nurse, confirmed that the mattress was not set according to the resident's actual weight, as required by both the care plan and the manufacturer's user manual. The resident was dependent on staff for most activities of daily living and had impaired skin integrity related to a sacral coccyx Stage 4 pressure injury. During interviews, the resident reported that the bed was not as firm as before, indicating a change in the mattress setting. The Director of Nursing also acknowledged that the LAL mattress needed to be set based on the resident's weight and comfort level to prevent deterioration of wounds or development of new pressure injuries. The user manual for the mattress confirmed that the pressure should be adjusted using the patient's weight as a guide.
Failure to Provide Dialysis Emergency Kit at Bedside
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis had a dialysis emergency kit (E-kit) at the bedside, as required for immediate intervention in case of complications such as unexpected bleeding from the hemodialysis access site. Observation and interview confirmed that the resident, who had diagnoses including end stage renal disease, hydronephrosis, and dependence on hemodialysis, did not have an E-kit available at the bedside. The resident's care plan specified the need for immediate intervention for dialysis-related complications, and the Director of Nursing confirmed that all dialysis residents should have an E-kit readily accessible. The deficiency was identified during a review of the resident's records, care plan, and through direct observation and staff interviews. The resident was noted to have moderately impaired cognition and required varying levels of assistance with daily activities. The facility's policy and procedures indicated the need for immediate action and supplies in the event of bleeding from the dialysis access site, but these supplies were not present at the resident's bedside at the time of the survey.
Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
A deficiency occurred when a resident with multiple left-sided rib fractures and high blood pressure, who was cognitively intact and able to make decisions, did not receive pain medication in accordance with physician orders. The resident had an active order for Dilaudid 1 mg by mouth every four hours as needed for moderate pain (pain scale 4-6). During a medication administration observation, a nurse assessed the resident's pain at a level of seven, which is categorized as severe pain, but still administered Dilaudid as ordered for moderate pain. The nurse stated that pain medication for severe pain was unavailable and planned to reassess and contact the physician for further orders. The facility's care plan indicated that Dilaudid should be administered as ordered by the physician, and facility policy required medications to be given in accordance with prescriber orders. The DON confirmed that the physician should have been notified to obtain appropriate orders for severe pain and acknowledged that the ordered parameters were not followed. Facility policy also defined a medication error as administering drugs not in accordance with physician orders or accepted professional standards.
Failure to Maintain Medication Refrigerator Within Required Temperature Range
Penalty
Summary
The facility failed to maintain the medication refrigerator (MR) within the required temperature range of 36 to 46 degrees Fahrenheit, as evidenced by temperature logs and direct observation. The MR temperature log showed that on two consecutive days, the temperature was recorded at 48 degrees Fahrenheit, which is above the recommended range. Additionally, during an observation in the medication room, the MR temperature was found to be 34 degrees Fahrenheit, which is below the required minimum. Both the Licensed Vocational Nurse and the Director of Nursing confirmed that maintaining the MR temperature within the specified range is necessary to ensure the efficacy and stability of stored medications. A review of the facility's policy and procedure on temperature control confirmed that drugs requiring refrigeration must be stored between 36 and 46 degrees Fahrenheit, and that daily temperature logs should be maintained to ensure compliance. The failure to keep the MR within the recommended temperature range was directly observed and acknowledged by facility staff, with no indication in the report of corrective actions taken at the time of the survey.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in two out of twenty-three resident rooms, as determined by observation, interview, and record review. The Client Accommodations Analysis indicated that the identified rooms had a total of 156 square feet of floor area and housed two beds, which does not meet the regulatory requirement for space per resident. The facility had submitted a waiver request for these rooms, stating that the space was sufficient for safe resident mobility and accessibility, and that care and services would not be impeded. During the health recertification survey, it was observed that the rooms in question allowed for adequate nursing care, comfort, and privacy. Staff, including a CNA and an LVN, reported that there was enough space to use necessary equipment such as Hoyer lifts and walkers, and residents were able to move freely within the rooms. No residents expressed concerns about the room sizes, and staff confirmed that care could be provided without issue. The facility administrator confirmed that a waiver had been requested for these rooms and that there had been no changes to bed occupancy.
Failure to Properly Handle Advance Directives
Penalty
Summary
The facility failed to ensure proper handling of Advance Directives (AD) for two residents, which could lead to treatment against their wishes. For Resident 99, the facility did not perform a screening for an AD upon admission, nor did they obtain a copy of the AD to maintain in the resident's medical record. This oversight was confirmed during an interview with the Social Service Director (SSD), who acknowledged that the screening for ADs is part of the facility's admission process. Additionally, Resident 99's family member confirmed that the resident had an AD, but the facility did not request a copy for the medical record. For Resident 9, the facility failed to ensure that the AD Acknowledgement form was filled out completely. The form lacked checks in the boxes indicating whether the resident had executed an AD. This was noted during a review of the resident's medical record and confirmed by the SSD, who stated that it was necessary to complete the form to respect the resident's treatment preferences. The Director of Nursing also acknowledged the incomplete form, emphasizing the need for it to be filled out by the SSD. The facility's policy requires that ADs be inquired about and documented upon admission, but this was not adhered to in these cases.
Deficiencies in IV Line Management and Labeling
Penalty
Summary
The facility failed to provide appropriate care and services for intravenous (IV) lines for three residents, leading to potential risks of infection and complications. For one resident, a PICC line port was observed to be exposed and not covered with a cap, contrary to the facility's policy on preventing intravenous catheter-related infections. This resident was admitted with sepsis and cellulitis, requiring IV medications via a PICC line, and the care plan aimed to avoid complications related to IV therapy. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that all PICC line ports should be capped when not in use to prevent infection. Another resident had a peripheral IV site that was not labeled with the date of insertion, which is against the facility's policy requiring labeling with the date, time, and nurse's initials. This resident was admitted with cellulitis and had a physician's order for the peripheral site dressing to be changed every 72 hours. Observations and interviews with nursing staff revealed that the lack of labeling made it difficult to determine when the dressing was last changed, increasing the risk of infection. A third resident had a PICC line dressing that was not labeled with the date of insertion or change. This resident was admitted with acute osteomyelitis and anemia and required assistance with personal hygiene and transfers. The facility's policy mandates that PICC line dressings be labeled and changed every 5-7 days to prevent bacterial accumulation and infection. The Infection Preventionist Nurse confirmed that the dressing should be labeled to ensure timely changes, highlighting a lapse in adherence to infection prevention protocols.
Deficiencies in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to provide necessary respiratory care and services for four residents receiving oxygen therapy, as per the facility's Policy and Procedure on Respiratory Therapy - Prevention of Infection. Resident 151, who was admitted with conditions including hemiplegia, hemiparesis, and pneumonitis, was observed not using oxygen, with the oxygen tubing found on the floor. Interviews with staff, including the Licensed Vocational Nurse and the Infection Preventionist Nurse, confirmed that the oxygen tubing should have been placed in a transparent bag when not in use to prevent contamination and infection. Resident 27, admitted with acute respiratory failure and pneumonitis, was observed using oxygen therapy without the oxygen tubing and humidifier bottle being labeled with the date of change. This labeling is crucial to ensure timely changes and prevent infection. Interviews with the Infection Preventionist Nurse and the Registered Nurse Supervisor highlighted the importance of labeling to maintain infection control standards. Resident 25, diagnosed with hydrocephalus and hypertension, used a facemask for breathing therapy that was not labeled with the date of use. The Infection Preventionist Nurse indicated that the facemask should be labeled and changed every seven days to prevent bacterial accumulation. Additionally, Resident 199, with pulmonary hypertension, had oxygen tubing touching a trash bin, which was identified as a contamination risk by the Licensed Vocational Nurse and the Director of Nursing. The facility's policy requires oxygen equipment to be stored properly to prevent infection, which was not adhered to in these cases.
Failure to Develop Individualized Care Plan for Resident with Cystitis
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for Resident 19, who was diagnosed with chronic cystitis and was prescribed Bactrim. Despite the facility's policy requiring a comprehensive care plan to be developed within seven days of the Minimum Data Set (MDS) assessment and no more than 21 days after admission, there was no clinical documentation of a care plan addressing Resident 19's cystitis or the use of Bactrim. This oversight was identified during a review of Resident 19's medical records, which revealed the absence of a care plan to guide staff in providing appropriate treatment. Resident 19 was admitted to the facility with diagnoses including chronic cystitis and overactive bladder. The resident's cognitive abilities were moderately impaired, and they were dependent on staff for various activities of daily living. Despite these needs, the facility did not create a care plan to address the resident's specific medical condition and medication regimen. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the lack of a care plan, acknowledging that it should have been developed to ensure the resident received necessary care and treatment.
Failure to Conduct Smoking Assessment for New Resident
Penalty
Summary
The facility failed to conduct a smoking assessment for a newly admitted resident, identified as Resident 100, who had a history of smoking for more than a specified number of years. This oversight was discovered during an observation in the facility's designated smoking area, where Resident 100 was seen smoking with a visitor. The resident's admission record indicated diagnoses of acute respiratory failure and hypertension, and the history and physical examination confirmed the resident's capacity to understand and make decisions. However, the medical record lacked any documentation of a smoking assessment. During an interview with Licensed Vocational Nurse 5, it was revealed that the facility was unaware of Resident 100's smoking status upon admission, and no smoking assessment was performed. The facility's policy, revised in October 2023, mandates that residents be informed of the smoking policy and evaluated for smoking status upon admission. The failure to adhere to this policy resulted in a deficiency, as the necessary assessment to ensure safe smoking practices was not conducted.
Failure to Supervise Resident Using Plate Guard
Penalty
Summary
The facility failed to provide adequate supervision to a resident who required the use of a plate guard during meals. The resident, who was admitted with diagnoses of hemiplegia and hemiparesis, had an order for a plate guard at mealtime and required supervision or assistance with eating. Despite these requirements, observations revealed that the resident was eating alone with the plate guard improperly positioned, leading to food spillage. Interviews with the Director of Nursing and a Certified Nurse Assistant confirmed that the resident needed assistance to use the plate guard effectively, and the Dietary Supervisor indicated that the plate guard should be positioned to accommodate the resident's dominant hand. The resident's care plan and order summary report indicated the need for supervision during meals, yet the resident was observed eating without the necessary assistance. The facility's policy on assistive devices emphasized the importance of maintaining and supervising the use of such equipment to support resident independence and safety. However, the lack of proper supervision and incorrect positioning of the plate guard during meals demonstrated a failure to adhere to these guidelines, potentially impacting the resident's nutritional status and independence during mealtime.
Inaccurate POLST Documentation for a Resident
Penalty
Summary
The facility failed to ensure accurate documentation of the Physician Orders for Life-Sustaining Treatment (POLST) for a resident, identified as Resident 25. The POLST, which is crucial for recording a patient's treatment preferences in emergencies, inaccurately indicated that the resident had an Advance Directive (AD). However, upon review, it was found that the resident did not execute an AD, as confirmed by the AD acknowledgment form and the Social Service Director (SSD). This inconsistency between the POLST and the AD acknowledgment form was acknowledged by the SSD, who admitted to incorrect documentation. Resident 25 was admitted with diagnoses including hydrocephalus and hypertension and required substantial assistance for personal hygiene and transfers. The inaccurate documentation in the POLST had the potential to cause miscommunication among healthcare providers, leading to inconsistent care and possibly administering treatment against the resident's wishes during emergencies. The facility's policy on charting and documentation emphasizes the need for objective, complete, and accurate records, which was not adhered to in this case.
Room Size Deficiency in Two Resident Rooms
Penalty
Summary
The facility failed to ensure that two of its rooms met the required square footage per resident in multiple resident rooms. Specifically, rooms 12 and 32, each housing two residents, were found to be 156 square feet, falling short of the 160 square feet minimum requirement. Despite this deficiency, observations indicated that residents in these rooms were able to ambulate freely and maneuver in their wheelchairs without difficulty. Nursing staff also had sufficient space to provide care with dignity and privacy, and there was adequate room for beds, side tables, dressers, and other medical equipment. During an interview, the Administrator acknowledged the deficiency and indicated plans to submit a room waiver request for the affected rooms. The waiver request letter stated that there was ample room to accommodate wheelchairs and other medical equipment, and that the health and safety of residents were not compromised. Interviews with residents revealed no concerns regarding the size of their rooms, suggesting that the deficiency did not adversely affect their well-being or the provision of care.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by not ensuring timely responses to the resident's call light, not assisting with activities of daily living (ADL) as per the care plan, and leaving the resident soiled in urine for prolonged periods. The resident, who had multiple diagnoses including a history of stroke, osteoarthritis, epilepsy, and mobility impairments, was totally dependent on staff for personal and toileting hygiene. Despite the care plan indicating the need for substantial assistance and frequent incontinence care, the resident reported having to wait for assistance to get out of bed and being left soiled due to staff shortages. Interviews with Certified Nursing Assistants (CNAs) revealed that due to staffing shortages, they were unable to change incontinence briefs and reposition residents every two hours as required. The CNAs admitted to only being able to change residents twice per shift and acknowledged delays in answering call lights. The facility's policies on answering call lights and supporting ADLs were not adhered to, leading to the resident's needs not being met in a timely and appropriate manner.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for six residents in accordance with physician's orders. For Resident 7, the care plan did not include a physician's order for Assisted Active Range of Motion (AAROM) exercises to both lower extremities. Additionally, the facility did not perform Passive Range of Motion (PROM) exercises for Resident 9's right upper extremity, Resident 10's lower extremities and right upper extremity, and Resident 11's lower extremities as indicated in their care plans. Furthermore, Active Range of Motion (AROM) exercises were not performed for Resident 13's lower extremities, and Resident 14 did not receive the prescribed left elbow splint and PROM exercises for the left upper extremity as indicated in the care plan. Resident 7 was admitted with multiple diagnoses including dementia and morbid obesity and required assistance with mobility and personal care. The care plan for Resident 7 included AAROM exercises for both lower extremities, but there was no corresponding physician's order. Resident 9, who had a history of cerebral infarction and severe cognitive impairment, did not receive PROM exercises for the right upper extremity on several documented dates. Similarly, Resident 10, who had hemiplegia and hemiparesis, did not receive PROM exercises for the lower extremities and right upper extremity on multiple occasions. Resident 11, with a history of falling and a displaced bimalleolar fracture, did not receive PROM exercises for the lower extremities as ordered. Resident 13, who had a right femoral neck fracture and other mobility issues, did not receive AROM exercises for the lower extremities on several dates. Lastly, Resident 14, who had hemiplegia and contractures, did not receive the prescribed left elbow splint and PROM exercises for the left upper extremity on multiple occasions. These failures had the potential to diminish the residents' quality of life related to a further decline in their physical and psychosocial well-being.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services (RNS) as ordered by the physician for six residents. For Resident 7, who had multiple diagnoses including dementia and morbid obesity, RNA services were not provided for five days in April 2024. The resident required assistance with mobility and personal care, and the lack of RNA services was confirmed through interviews and record reviews. Similarly, Resident 9, who had a history of cerebral infarction and severe cognitive impairment, did not receive RNA services for four days in April 2024. The resident was dependent on staff for most self-care activities and mobility, and the absence of RNA services was also confirmed through documentation review and interviews. Resident 10, diagnosed with hemiplegia and hemiparesis, did not receive RNA services for six days in April 2024. The resident was dependent on staff for toileting hygiene, showering, and mobility. The lack of RNA services was confirmed through record reviews and interviews. Resident 11, who had a history of falling and a displaced bimalleolar fracture, did not receive RNA services for three days in April 2024. The resident had severe cognitive impairment and was dependent on staff for all self-care activities and mobility. The absence of RNA services was confirmed through documentation review and interviews. Resident 13, who had multiple diagnoses including a right femoral neck fracture and heart failure, did not receive RNA services for three days in April 2024. The resident was dependent on staff for various self-care activities and transfers. The lack of RNA services was confirmed through record reviews and interviews. Lastly, Resident 14, diagnosed with hemiplegia and contractures, did not receive RNA services for four days in April 2024. The resident was dependent on staff for most self-care activities and mobility. The absence of RNA services was confirmed through documentation review and interviews. The Director of Nursing acknowledged that RNA services must be provided consistently to prevent further decline in residents' range of motion and mobility, but staffing shortages led to RNAs being reassigned to CNA duties, resulting in the failure to provide the necessary services.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff, including CNAs and RNAs, to provide care for seven of 15 sampled residents. This deficiency was observed through various interviews and record reviews, revealing that residents' needs and preferences were not met, and physician-ordered RNA services were not consistently provided. For instance, Resident 1 had to wait until 10 AM to get out of bed due to a lack of staff, and incontinence brief changes were not performed as frequently as required. Multiple CNAs reported being overworked and unable to respond to call lights promptly, leading to delays in care and resident dissatisfaction. The report also highlighted that RNA services were not provided as ordered by the physician for several residents. Resident 7, for example, did not receive RNA services on multiple days in April 2024, as documented in the facility's records. Similar deficiencies were noted for Residents 9, 10, 11, 13, and 14, who did not receive their prescribed RNA services on various dates. Interviews with RNAs confirmed that they were often reassigned to perform CNA duties due to staffing shortages, leaving them unable to fulfill their RNA responsibilities. Interviews with facility staff, including CNAs, LVNs, and the DON, revealed a consistent theme of staffing shortages and inadequate responses from the Director of Staff Development (DSD). Staff reported that the DSD did not call for additional help or use registry staff effectively, leading to an overwhelming workload and insufficient care for residents. The facility's policy on staffing emphasized the need for sufficient numbers of skilled staff to meet residents' needs, but this was not adhered to, resulting in significant care deficiencies.
Failure to Verify Competencies and Address Staffing Shortages
Penalty
Summary
The facility failed to verify the competencies and skill sets of the nursing staff, leading to several deficiencies. Three of nine sampled CNAs did not have active CNA certifications. Interviews revealed that errors in filling out certification renewal paperwork and providing required in-services delayed the renewal process. Despite expired certifications, some CNAs continued to work in non-resident care-related duties. The facility's policy required maintaining current certifications, but this was not adhered to, as evidenced by the employee files and timecards reviewed by the Director of Nursing (DON). Additionally, the facility's DSD job description mandated maintaining employee files and health records, which was not followed in this case. The facility also failed to conduct Skills Competency tests for newly hired CNAs before they began working independently. Performance evaluations and Skills Competency tests were supposed to be conducted upon hire and annually, but there was no documented evidence that these tests were performed for two newly hired CNAs. The DON confirmed the absence of these tests and noted that the Pre-Employment Reference Verification Checklist for one CNA was questionable. The facility's DSD job description required assessing the learning needs of personnel and monitoring continuity between classroom and clinical application, which was not done. Furthermore, the facility did not ensure that all nursing staff had current CPR/BLS certifications. Four sampled nursing staff members lacked documented evidence of current CPR/BLS certifications. The DSD was responsible for verifying these certifications upon hiring and organizing renewal classes if needed, but this was not done. Interviews with staff revealed that the DSD did not address staffing shortages, which affected the quality of care provided to residents. Staff reported being overwhelmed with the workload, unable to take breaks, and struggling to provide adequate care due to insufficient staffing. The facility's policy required providing sufficient numbers of staff with the necessary skills and competency, which was not met.
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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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