Sequoia Vista
Inspection history, citations, penalties and survey trends for this long-term care facility in Visalia, California.
- Location
- 3710 West Tulare Avenue, Visalia, California 93277
- CMS Provider Number
- 055916
- Inspections on file
- 55
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Sequoia Vista during CMS and state inspections, most recent first.
The facility allowed a respiratory therapist to provide respiratory care without verifying state licensure, despite a job description and a license verification policy requiring a valid, unrestricted state license. Human Resources hired the therapist and did not complete or document required license verification with the state regulatory agency, later confirming the therapist never held a state license during employment. This failure resulted in an unlicensed individual delivering respiratory services to residents and was cited as a deficiency.
A resident with orders for buspirone, citalopram, and valproic acid repeatedly refused these psychotropic medications over multiple days, as documented on the MAR. Review of progress notes showed no documentation that the physician was notified of these refusals, despite the IDON acknowledging that notification should occur after multiple refusals. The facility’s policy on residents’ rights and treatment requires documenting the refusal, the reason, education provided, and physician notification, but the record lacked evidence that the physician had been informed.
A resident with dementia, anxiety, and recent aggressive behaviors had a new order for Risperdal Consta 37.5 mg IM every 14 days. On the scheduled administration date, the MAR showed the dose was not given, and a progress note documented that the medication was pending pharmacy delivery. The IDON confirmed that the physician was not notified that the ordered antipsychotic dose was unavailable, despite facility policy requiring physician notification and treatment of missed doses as medication errors.
A resident with rheumatoid arthritis was discharged from a hospital on methotrexate 20 mg PO weekly, but when orders were entered into the facility’s system, the drug was incorrectly ordered and administered as 20 mg PO daily. The electronic order entry generated a medication alert stating the dose and frequency exceeded usual weekly dosing, yet staff did not clarify or correct the order, and the consultant pharmacist’s drug regimen reviews noted no recommendations. Over several weeks, the MAR shows daily methotrexate administration, after which the resident developed sore throat, dysphagia, epistaxis, oral and facial swelling, and bloody stool, leading to transfer to the hospital. Hospital records confirmed the resident had been receiving methotrexate daily, diagnosed methotrexate toxicity with pancytopenia, multi-organ dysfunction, sepsis, and acute renal failure, and the resident ultimately died; the death certificate cited acute renal failure and methotrexate toxicity, stating the resident ingested a toxic amount of methotrexate. Facility policy required adherence to the six rights of medication administration, use of drug references, special handling of immunosuppressants, and correction of discrepancies, which were not followed in this case.
A resident with Type 1 DM and hyperglycemia had physician orders for twice-daily Insulin Degludec with instructions to notify the MD for BS readings greater than 250. Review of the MAR showed multiple BS values above 250 over the month, yet there was no documentation that the MD was notified of these elevated results. The care plan directed staff to administer insulin as ordered and report signs and symptoms of hyperglycemia, and facility policy required reporting critical test results to the physician, but the DON confirmed that documentation of MD notification for these high BS readings was not available.
The facility did not complete required annual performance evaluations for two CNAs in accordance with its policy. Both CNAs had their last evaluations documented more than a year earlier, and the HR manager acknowledged that new evaluations should have been completed around their employment anniversary dates. The Administrator confirmed that evaluations are expected yearly, and the written policy states that supervisors must conduct annual performance discussions at or around each employee’s anniversary date, but this was not done, resulting in overdue evaluations.
A resident with metabolic encephalopathy, mobility impairment, and cognitive communication deficit, but cognitively intact per BIMS, reported that an unknown CNA was rough and hurt her back while assisting her on and off the toilet during a p.m. shift when her usual CNA was at lunch. The resident and a family member relayed this allegation of physical abuse to a CNA, who immediately informed an LVN. The LVN admitted she did not report the allegation to the administrator/abuse coordinator or DON as required, stating she was overwhelmed and forgot. The SSD and administrator learned of the allegation only the next day from the family, despite facility policy requiring that all abuse allegations be reported to the administrator and appropriate agencies immediately, and no later than two hours after the allegation is made.
A resident with a history of elopement and moderate cognitive impairment was not monitored or documented every hour as required by her care plan. Staff failed to consistently check her whereabouts, leading to her unsupervised exit from the facility. She was found the next morning by police, suffering from hypothermia and other medical complications, and required hospitalization.
A resident involved in a peer altercation sustained visible facial injuries, but the RP and physician were not properly notified as required. Documentation indicated notification, but interviews and record review showed the RP was unaware until a visit. The facility also failed to assess, treat, or monitor the injuries according to policy, and staff were unclear about notification responsibilities.
A resident, assessed as cognitively intact, reported feeling intimidated and bullied by a social worker during a conversation in their room. An LVN present described the social worker's responses as snarky, which did not align with the facility's policy requiring respectful communication with residents.
A resident reported $600 missing, and although staff initiated an internal investigation and notified the resident's family, the facility did not report the alleged misappropriation to the Department of Public Health, Ombudsman, Adult Protective Services, or Law Enforcement within 24 hours as required by policy. The resident was cognitively intact, and staff interviews confirmed the delay in external reporting.
A resident's Inventory of Personal Effects (IPE) was not signed by the resident or their representative at admission, contrary to facility policy requiring all personal items to be inventoried and acknowledged. The Social Service Director confirmed the omission during a review.
A resident with major depressive disorder and social anxiety, who prefers to stay in her room, was forced to leave her room and remain in the hallway in her bed for about an hour during a scheduled deep cleaning, despite her refusal and documented preferences. Multiple staff members confirmed the resident's right to remain in her room was not honored, resulting in significant distress and a violation of her rights.
A resident was not given advance written notice before a new roommate, who exhibited frequent outbursts and confusion, was moved into his room. The facility did not monitor for compatibility as required, resulting in ongoing distress, sleep disruption, and a resident-to-resident altercation. Staff confirmed the lack of documentation and that the two residents were not compatible.
A resident's responsible party filed a grievance about the resident being found in a soiled gown, but did not receive a written decision as required by facility policy. The administrator confirmed the grievance was resolved but could not provide documentation that a written response was given, resulting in a violation of the resident's rights.
A resident with moderate cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unsupervised after staff failed to consistently report and intervene on her attempts to exit. The resident was later found by police outside the facility. Staff interviews and record reviews confirmed that the resident's behaviors were known but not always communicated or addressed according to facility policy.
A resident experienced repeated episodes of low blood pressure after dialysis, with multiple readings below normal limits. Despite the resident and family reporting these concerns and facility policy requiring physician notification and documentation for significant changes, staff did not document interventions or notify the physician. This failure to address and record the resident's change in condition did not meet professional standards of quality.
The facility failed to provide routine nail care for two residents, resulting in untrimmed nails and debris accumulation. Observations and interviews revealed that nail care, scheduled for Sundays, was not performed. One resident, a diabetic, did not receive the required care from a licensed nurse as per facility policy.
The facility did not ensure an RN was on duty for eight hours daily, seven days a week, as required by policy. On specific dates in November, no RN was present for the required duration, confirmed by the HR manager and staff schedules.
The facility did not complete Performance Evaluations for three CNAs, as identified during a review with HR. CNAs hired in 2021, 2022, and 2023 had no evaluations in their files, contrary to the facility's policy requiring HR to notify managers of upcoming evaluations. This oversight could impact staff awareness of areas needing improvement.
A facility failed to ensure proper communication between the Dietary Manager and Registered Dietitian regarding a malfunctioning refrigerator used to store TCS foods. The refrigerator was not maintaining the required temperature, leading to improper storage of foods like pudding cups and milk. The issue was identified but not communicated effectively, resulting in continued use of the faulty refrigerator, which posed a risk of bacterial growth.
The facility failed to maintain sanitary kitchen conditions, use pasteurized eggs, and ensure proper food storage temperatures. Observations revealed unsanitary utensils, non-pasteurized eggs served to residents, uncovered food delivery, and a malfunctioning refrigerator with temperatures above safe levels. Staff acknowledged these issues, which were contrary to the facility's policies.
The facility failed to conduct timely smoking assessments for two residents, resulting in a lack of safety evaluation for smoking. A resident admitted on an unspecified date and another admitted on May 1, 2022, did not receive required quarterly assessments after September 2023. The facility's policy mandated smoking assessments during admission and quarterly MDS assessments to determine supervision needs. This oversight posed a potential risk of burns while smoking.
A medication error rate of 11.63% was observed when an LVN administered medications orally instead of via G-tube as ordered for a resident. The medications, including aspirin, docusate sodium, metformin, Keppra, and Januvia, were crushed and mixed with pudding before being given. The LVN acknowledged the error and the facility's policy requires adherence to the prescribed route of administration.
The facility failed to implement Enhanced Barrier Precautions for residents with indwelling devices, as required by their policy. Observations showed a lack of signage and PPE carts, and staff interviews revealed a lack of awareness about the necessity of these precautions. Despite policy requirements, the facility did not ensure precautions were in place for residents with devices like Foley and dialysis catheters.
A facility failed to ensure accurate informed consent for a psychotropic medication for a resident with severe cognitive impairment. The resident, with a BIMS score of 2, signed their own consent for Zoloft, contrary to the facility's policy requiring a higher cognitive score for self-consent. The DON acknowledged the error, as the policy mandates assessing decision-making capacity.
A resident with schizophrenia and dementia was observed over several days with greasy hair, a strong smell of urine, and wearing the same dirty clothes, with no personal clothing available in her closet. Staff interviews revealed that the resident was often left to perform her own personal care, and her clothing was accidentally discarded. The facility failed to adhere to its policies on maintaining resident dignity and personal belongings.
A resident with lower extremity impairments was unable to participate in group activities due to the unavailability of a Geri-chair, which is necessary for their mobility. Despite the resident's interest in activities, the facility did not provide the necessary equipment consistently, resulting in no participation in group activities for two months. The facility had limited Geri-chairs and no schedule for their use among dependent residents.
A facility failed to notify a resident's family when the resident experienced a change in condition and was transferred to a hospital. The resident was unresponsive on two occasions and taken to the hospital by EMTs. Although the resident was their own Responsible Party (RP), the Director of Nursing (DON) acknowledged that the family should have been informed, as per the facility's policy on Notification of Changes.
The facility failed to provide an ABN to a resident who self-discharged from Medicare Part A and left another resident's ABN incomplete by not checking required option boxes. The Admissions Coordinator acknowledged these oversights, which could lead to the facility being held liable for care costs.
The facility failed to conduct PASRR Level II evaluations for two residents who tested positive for Serious Mental Illness (SMI) in their Level I screenings. Despite the facility's policy requiring a Level II evaluation prior to admission and within 40 days if the resident stays longer than 30 days, these evaluations were not performed, as confirmed by the DON.
A resident was admitted without a diet order, leading to potential unmet nutritional needs. The diet order was documented four days later, indicating a controlled carbohydrate diet. Interviews with the DON and ADON confirmed the absence of a physician-ordered diet upon admission, contrary to the facility's policies requiring immediate care orders, including dietary needs.
A resident experienced unmet communication needs due to the facility's failure to provide necessary hearing services and adaptive equipment. Despite the resident's expressed difficulty in hearing and desire for hearing aids, the Social Service Designee was unaware of any audiology services being used, and the resident had not received a hearing test. This was contrary to the facility's policy requiring access to hearing services.
A facility failed to document the quantity consumed of a nutritional supplement for a resident with significant weight loss. The resident did not consume the health shake due to disliking it, and the facility's documentation system did not itemize fluid intake, hindering accurate nutrition assessments. The MAR only indicated the shake was provided, not consumed, and the ADON acknowledged the lack of a system to document intake, preventing effective monitoring and timely intervention.
An LVN failed to secure and properly dispose of a controlled medication during a medication pass. The LVN left a cup containing Tramadol and other medications unattended on a cart and later disposed of them improperly in a hazardous waste container without using a solvent. The facility's policy requires controlled medications to be destroyed with a witness and in a manner that renders them unfit for consumption.
The facility did not follow the meal tray tickets and planned menus for two residents, potentially affecting their nutritional goals. A resident's lunch tray lacked the correct portion of garlic bread, and another resident's tray was missing the prescribed 4 oz of 2% milk. The facility's policy requires adherence to physician-prescribed diet orders, which was not followed in these instances.
A facility failed to serve a resident the correct therapeutic diet as per the physician's order. The resident, who required a pureed texture diet, was served a meal with regular texture food. The Registered Dietitian confirmed the discrepancy, noting two conflicting meal tray tickets on file. The facility's policy required diet orders to be communicated and provided accurately, which was not followed in this instance.
The facility did not follow its policy for labeling and dating food stored in the resident designated refrigerator (RDR). During an observation, undated and unlabeled food items were found in the RDR. A CNA and an LVN confirmed that all food should be dated and labeled with the resident's name, as per the facility's policy.
A CNA in an LTC facility used profanity while providing care to a resident with severe cognitive impairment, as confirmed by staff and the resident's roommate. The incident was documented as verbal abuse, violating the facility's policy on resident rights to respect and dignity.
The facility did not verify all employment references for a CNA before hiring, as required by its policy. Only one of two employment references and two personal references were verified, leaving one employment reference unchecked. This oversight was acknowledged by the Director of Staff Development and confirmed by the Assistant Administrator, who stated that both employment references should have been verified before personal references.
A facility failed to notify a resident's responsible party about redness to the resident's bilateral buttocks upon admission. The responsible party confirmed they were not informed, and both an LVN and the DON acknowledged the lack of documentation regarding the notification. The facility could not provide a policy for responsible party notification.
A resident's dignity was violated when a CNA made an inappropriate comment during care, referring to the resident's condition in a derogatory manner. The comment was overheard by the resident, who reported it to the DON. Interviews confirmed the incident, and the facility's Administrator acknowledged the comment was against policy.
A resident's family reported rushed care and a bad attitude from two CNAs. Despite instructions to provide in-service training, one CNA returned to work without receiving it. The DON assumed training was completed, but the DSD was unaware of the CNA's return. The facility lacked a policy on in-service training, leading to this oversight.
A resident in a long-term care facility did not receive prescribed doses of Lovenox and Depakote due to unavailability, and the physician was not notified of these missed medications. The facility's staff, including an LVN and the DON, acknowledged that the physician should have been informed, but there was no documentation to confirm this notification. The administrator could not provide a policy on notifying physicians about unavailable medications.
Unlicensed Respiratory Therapist Allowed to Provide Care
Penalty
Summary
The facility failed to ensure a respiratory therapist was properly licensed by the state before hire and while providing care. Human Resources (HR) records showed the therapist was hired as a respiratory therapist on 7/14/25 and worked in that role until termination on 4/14/26. The termination form documented the reason for termination as failure to possess the licensure or certification required for the position. During interview, HR stated that respiratory therapist licenses were supposed to be verified with the Department of Consumer Affairs prior to employment, but HR could not provide evidence that this therapist’s state license had been verified at hire and confirmed the therapist did not have a state license at the time of hire or termination. The facility’s respiratory therapist job description required a valid, unrestricted state license, and the facility’s undated License Verification policy assigned the HR Director or designee responsibility for maintaining and ensuring the validity and current status of individual licensure, which was not carried out in this case. The report states that this failure resulted in the therapist providing respiratory care to residents without a state license and created the potential to put residents at risk for harm. No additional resident-specific clinical details or medical histories were provided in the report.
Failure to Notify Physician of Repeated Psychotropic Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician when a resident repeatedly refused prescribed psychotropic medications. Review of the resident’s Order Summary Report showed active orders for buspirone for anxiety twice daily starting 12/25/25, citalopram for depression once daily starting 3/4/26, and valproic acid for psychiatric disorders twice daily starting 3/31/26. The Medication Administration Record for 4/1/26–4/30/26 documented that citalopram was refused on 4/1, 4/5, 4/7, and 4/8, and that buspirone and valproic acid were refused on 4/1, 4/2, 4/4, 4/5, 4/6, 4/7, and 4/8. During an interview and concurrent record review with the Interim Director of Nursing on 4/13/26, the resident’s progress notes from 4/1/26–4/8/26 were examined, and there was no documentation that the physician had been informed of these multiple medication refusals. The IDON stated that the physician should have been notified when the resident refused the medications three times. The facility’s policy titled “Residents’ Rights Regarding Treatment and Advance Directives” requires documentation of what was refused, the reason for refusal, how the resident was educated about consequences, and that the physician was notified of the refusal and the resident’s response. The records did not contain documentation that the physician was notified as required by this policy.
Failure to Notify Physician When Antipsychotic Medication Was Unavailable
Penalty
Summary
The facility failed to ensure physician notification when an ordered antipsychotic medication was not available for a resident with dementia and recent aggressive behaviors. A psychological evaluation and medication recommendation dated 3/30/26 documented that the resident had two recent episodes of significant aggressive acting-out behavior, and recommended increasing Risperdal Consta to 37.5 mg IM every two weeks. The physician’s order summary dated 4/1/26 reflected an order for Risperdal Consta 37.5 mg IM every 14 days in the evening, related to unspecified dementia with anxiety, with a start date of 3/31/26. The MAR for 3/1/26–3/31/26 showed that the Risperdal Consta dose scheduled for 4 p.m. on 3/31 was not administered, with a code indicating to see the progress notes. A progress note entered at 9:27 p.m. on 3/31 documented that the Risperdal Consta dose was pending pharmacy delivery. During interview and concurrent record review, the Interim DON confirmed that the physician was not notified that the medication was unavailable for administration on 3/31 and acknowledged that the physician should have been notified. The facility’s policy on Unavailable Medications states that if a resident misses a scheduled dose, staff must follow procedures for medication errors, including physician and family notification, completion of a medication error report, and monitoring for adverse reactions to omission of the medication.
Fatal Methotrexate Dosing Error and Ignored Medication Alert
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors by not following its Medication Administration policy regarding right dose, right time, and appropriate response to medication alerts. A resident with rheumatoid arthritis was discharged from an acute hospital to the facility with an order for methotrexate 20 mg by mouth every Friday, as documented in the hospital discharge instructions. The resident’s diagnoses included rheumatoid arthritis, shortness of breath, and difficulty walking, and the Minimum Data Set also reflected an active diagnosis of rheumatoid arthritis. Despite this, when the orders were entered into the facility’s system, the Physician’s Order Sheet showed methotrexate 20 mg by mouth every day instead of weekly. When the methotrexate order was entered into the facility’s computer system, a medication alert was generated stating that the order was outside the recommended dose or frequency, specifying that the dosing regimen of 2 tablets daily exceeded the usual dosing regimen of 0.25 mg to 2.5 mg tablets every 7 days and that the daily frequency exceeded the usual weekly frequency. Facility staff interviews indicated that nurses understood medication alerts to mean there was a contraindication or concern requiring contact with the pharmacy or physician to clarify safety, but there was no evidence this alert was acted upon. The Medication Administration Record for November and December showed that the resident received methotrexate 20 mg by mouth daily on multiple dates over several weeks, consistent with the incorrect daily order. The care plan identified methotrexate as a black box warning medication with potential for bone marrow suppression and called for monthly drug regimen review by a pharmacist, yet the pharmacist’s order history and drug regimen review documents showed the methotrexate 20 mg daily order was reviewed on two dates in November with no recommendations and was listed as reviewed without requiring any recommendations. Progress notes documented that in mid-December the resident developed sore throat, difficulty swallowing, epistaxis, lip and chin swelling, and bloody stool. Nursing staff notified the physician, obtained orders including nasal spray, and the resident was sent to the hospital for further evaluation due to ongoing nosebleeds. Hospital emergency documentation recorded that the resident presented with life-threatening cytopenias, critical neutropenia, thrombocytopenia, anemia, acute bleeding, and organ dysfunction, with a diagnosis of methotrexate toxicity with multi-organ involvement and sepsis, and confirmed with the nursing home that the resident had been receiving methotrexate daily, with suspected overdose. The hospital history and physical also documented confirmation from the nursing home that methotrexate was being given daily. The hospital discharge summary described a prolonged course for methotrexate toxicity with severe thrombocytopenia, pancytopenia, septic shock, acute renal failure requiring dialysis, and respiratory failure, after which the resident was transitioned to comfort care and hospice. The death certificate listed acute renal failure, methotrexate toxicity, and rheumatoid arthritis, and stated that the resident ingested a toxic amount of methotrexate. The facility’s Medication Administration policy required medications to be administered as ordered by the physician, in accordance with professional standards, ensuring the six rights including right dosage and right time, use of drug reference material if unfamiliar, special handling of immunosuppressant medications, and reporting and correcting discrepancies, which were not followed in this case. Interviews with facility staff further clarified the actions and inactions leading to the deficiency. The DON stated that the resident was admitted in November and began having swallowing problems and nosebleeds around the middle of December, and that the resident was sent to the hospital due to continued nosebleeds. The DON reported that near the end of December a hospital case manager informed her that the resident appeared to have been receiving methotrexate daily instead of weekly. Upon comparing the facility MAR with the hospital discharge orders, the DON confirmed the resident had been given 20 mg methotrexate daily instead of 20 mg weekly, and that the pharmacy-supplied bubble pack was labeled for daily administration. The nurse who admitted the resident and entered the discharge orders into the facility system stated she entered the orders but could not recall how or why the methotrexate frequency was changed from weekly to daily. The ADON stated that this error could have been caught and was unsure why the system failed. The manufacturer’s black box warning for methotrexate, reviewed by surveyors, emphasized that methotrexate can cause serious, potentially fatal toxic reactions and should only be used by physicians experienced with antimetabolite therapy, underscoring the high-risk nature of the medication that was not properly managed according to facility policy and system alerts.
Failure to Notify Physician of Critically Elevated Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order and notify the physician when a resident’s blood sugar (BS) exceeded 250. The resident had Type 1 diabetes mellitus with hyperglycemia and physician orders for Insulin Degludec to be administered subcutaneously twice daily, with instructions to hold the insulin if BS was less than 90 and to notify the MD if BS was greater than 250. Review of the Medication Administration Record for the month showed multiple BS readings above 250, including values of 330, 342, 341, 301, 383, and 299 while the resident was on a 23-unit twice-daily dose, and subsequent readings of 335, 372, 252, 257, 325, and 324 after the dose was changed to 28 units twice daily. The resident’s care plan documented that the resident had diabetes mellitus and directed staff to administer Insulin Degludec as ordered and to monitor, document, and report signs and symptoms of hyperglycemia to the MD as needed. During an interview and concurrent record review with the DON, the facility was unable to provide documentation that the MD had been notified of any of the BS results above 250. The DON stated that the nurses should have notified the MD when the BS result was above 250, consistent with the physician’s order. The facility’s undated policy and procedure for Blood Glucose Monitoring stated that it is the policy of the facility to perform blood glucose monitoring for diabetic residents as per physician’s orders and to report critical test results to the physician in a timely manner. Despite these orders and policies, there was no documentation that the physician was notified of the elevated BS values identified in the resident’s record review.
Overdue Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to follow its policy and procedure for conducting annual performance evaluations (PEs) for two certified nursing assistants. Review of the employee roster showed both CNAs were hired on 5/1/19. Record review with the Human Resource/Payroll Manager on 3/9/26 showed that each CNA’s last PE was completed on 7/17/24, and the HRPM stated that both should have had PEs completed in July 2025. In an interview, the Administrator confirmed that PEs are supposed to be done yearly. Review of the facility’s undated Performance Evaluations policy indicated that supervisors are to complete, review, and conduct performance discussions annually at or around the employee’s anniversary date, but this was not done for the two CNAs, resulting in overdue performance evaluations. No resident-specific medical history or condition was mentioned in relation to this deficiency.
Failure to Timely Report Resident’s Allegation of Rough Handling During Toileting
Penalty
Summary
The deficiency involves the facility’s failure to ensure an allegation of abuse was promptly reported to the abuse coordinator as required by policy. Resident 1 was admitted with metabolic encephalopathy, difficulty in walking, cognitive communication deficit, bilateral lower extremity range-of-motion impairment, and was wheelchair-bound and dependent for transfers. An MDS dated 1/30/26 documented that the resident was cognitively intact with a BIMS score of 13. On 1/28/26 during the p.m. shift, the resident reported that an unknown CNA who assisted her to and from the restroom while her regular CNA was on lunch had been rough and hurt her back while providing care, which the facility categorized as an allegation of physical abuse. A SOC 341 form dated 1/29/26 documented the resident’s report that an unknown staff member was rough while assisting her to the restroom on the 1/28/26 p.m. shift. Progress notes dated 1/30/26 at 1:57 p.m. indicated that the IDT met to discuss the staff-to-resident alleged abuse that occurred on 1/28/26, and that the resident’s granddaughter had found the resident crying and was told by the resident that a female staff member had been rough and hurt her back while helping her to the bathroom. The resident stated the staff member was not her usual CNA but was helping out during the CNA’s lunch break and was unable to identify the CNA involved. Multiple staff interviews confirmed that the allegation was reported by the resident and her family to CNA 3 during the 1/28/26 p.m. shift, and that CNA 3 relayed the allegation to LVN 1 that same evening. LVN 1 acknowledged that she did not report the allegation to the administrator (abuse coordinator) or the DON, stating she was overwhelmed and it slipped her mind, and further acknowledged it should have been reported right away. The SSD and administrator both stated they did not become aware of the allegation until the following day when the family reported it, and both indicated that staff should have reported the allegation to the abuse coordinator immediately. The facility’s abuse, neglect, and exploitation policy required reporting all alleged violations to the administrator and appropriate agencies immediately, but not later than two hours after the allegation is made when the events involve abuse or result in serious bodily injury, which did not occur in this case.
Failure to Monitor and Document Whereabouts of High-Risk Resident Resulting in Elopement and Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to monitor and document the hourly whereabouts of a resident identified as high risk for elopement, as required by the resident's care plan. The care plan specified that the resident, who had a history of elopement and impaired safety awareness, should be monitored every hour. However, documentation in the Point of Care Response History showed that staff did not consistently check or record the resident’s whereabouts every hour, with significant gaps between documented checks. Staff interviews confirmed that the resident was last seen in her room in the evening, but was later discovered missing, and staff were unable to determine when or how she exited the facility. The resident involved had diagnoses including schizophrenia, anxiety disorder, and major depressive disorder, and was assessed as having moderate cognitive impairment and the ability to walk. She had a prior history of elopement from the facility. On the night of the incident, staff last observed her in her room, but she was later found to be missing. Despite a search of the facility and notification of the DON and police, the resident was not located until the following morning, when she was found by police approximately a mile away from the facility, exposed to cold weather conditions and without shoes. Medical evaluation after the incident revealed that the resident suffered from hypothermia, leukocytosis with left shift, and metabolic acidosis, requiring hospitalization. The facility’s policy required systematic monitoring and management of residents at risk for elopement, including regular assessment, care planning, and supervision, but these measures were not effectively implemented in this case. Staff interviews and documentation review confirmed that the required hourly monitoring was not performed or recorded as specified in the care plan, directly contributing to the resident’s unsupervised exit and subsequent medical complications.
Failure to Notify Responsible Party and Physician of Resident Altercation and Injuries
Penalty
Summary
The facility failed to notify the responsible party (RP) and the physician when a resident was involved in a resident-to-resident altercation and subsequently sustained visible injuries, including a cut under the left eye, bruising on the left cheek, and scabs to the left side of the nose and under the left eyebrow. Despite documentation indicating that the RP was notified, interviews with staff and the RP revealed that the notification did not occur as required. The RP only became aware of the injuries during a visit and was not informed about the altercation or the resulting wounds. Staff interviews further confirmed confusion and lack of clarity regarding who was responsible for notifying the RP, with documentation not matching actual communication events. Additionally, the facility did not assess, treat, or monitor the resident's injuries in accordance with its own policies. The ADON and Administrator were unaware of the full extent of the resident's injuries until they were observed during a visit, and there was no documentation of assessment, treatment, or physician notification regarding the wounds. The facility's policies required notification of changes in condition, accidents, and new treatments, but these procedures were not followed in this instance.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
A deficiency occurred when a social worker (SW) failed to treat a resident with respect and dignity during a conversation in the resident's room. According to a Licensed Vocational Nurse (LVN) who was present, the SW responded to the resident's questions with a snarky attitude. The resident, who was assessed as cognitively intact with a BIMS score of 15, reported feeling intimidated and bullied by the SW during the interaction. The facility's policy on promoting and maintaining resident dignity requires staff to speak respectfully to residents, which was not followed in this instance.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to follow its policy and procedure regarding the timely reporting of an alleged misappropriation of resident property for one resident. On 8/10/25, a resident reported $600 missing, and this was documented in the Theft & Loss Form and in the resident's progress notes. The CNA notified the RN supervisor, who assisted in searching for the missing items, and the resident's daughter was informed. The resident, who was cognitively intact as indicated by a BIMS score of 15/15, completed a theft and loss form, which was submitted to Social Services. However, the incident was not reported to the Department of Public Health, Ombudsman, Adult Protective Services, or Law Enforcement within 24 hours as required by facility policy. Interviews with facility staff confirmed that the required notifications were not made within the specified timeframe. The Social Service Director acknowledged that the incident should have been reported to the appropriate authorities, regardless of the family's wishes. The Ombudsman confirmed that their office was not notified, and the Administrator admitted that the delay occurred because the amount of missing money was unclear during the investigation. Review of the facility's policy confirmed the requirement to notify authorities within 24 hours of any suspected misappropriation of resident property.
Failure to Obtain Resident Signature on Inventory of Personal Effects at Admission
Penalty
Summary
The facility failed to follow its policy and procedure regarding the inventory of personal effects for one resident at the time of admission. Specifically, the Inventory of Personal Effects (IPE) form for the resident, dated 4/10/25, was not signed by the resident or their representative, as required by facility policy. During an interview and record review, the Social Service Director confirmed that the IPE should have been signed to indicate that all belongings were properly inventoried upon admission. The facility's policy states that all resident personal items must be inventoried at admission and reviewed by the social services designee and the resident's representative, but this process was not completed as documented.
Resident's Right to Room Choice Not Respected During Deep Cleaning
Penalty
Summary
The facility failed to honor a resident's right to self-determination and choice by not allowing her to remain in her room during a scheduled deep cleaning. The resident, who has a history of major depressive disorder and social anxiety, prefers to stay in her room and avoid social situations, as documented in her care plan and confirmed by multiple staff interviews. Despite her clear preference and refusal to leave, she was removed from her room and placed in the hallway in her bed for approximately one hour while her room was cleaned. This action caused the resident significant distress, including anxiety and being nearly in tears. Interviews with facility staff, including the social service designee, LVN, CNA, housekeeper, DON, and administrator, all confirmed the resident's preference to remain in her room and acknowledged that she should not have been forced to leave. The facility's own policy on resident rights also states that residents have the right to make choices about aspects of their life in the facility that are significant to them, including remaining in their room. The failure to respect the resident's choice resulted in a violation of her rights and caused her emotional discomfort.
Failure to Provide Advance Notice and Monitor Roommate Compatibility
Penalty
Summary
The facility failed to provide advance written notice to a resident prior to assigning a new roommate, as required by policy. The resident was not informed in writing before another resident, who was known to have frequent outbursts and confusion, was moved into his room. Multiple staff members, including the Social Service Assistant, Assistant Director of Nurses, and Licensed Vocational Nurse, confirmed that there was no documented evidence of written notification or monitoring for compatibility following the room change. The facility's policy requires advance notice and monitoring for 72 hours to ensure compatibility, but these steps were not followed or documented. As a result of this failure, the resident experienced significant distress, including inability to sleep due to the new roommate's constant yelling and outbursts. The resident reported the issue to several staff members but stated that nothing was done to address his concerns. Staff interviews confirmed that the two residents were not compatible as roommates, and no monitoring for compatibility was documented in the clinical records. This led to a resident-to-resident altercation and a violation of the resident's rights.
Failure to Provide Written Grievance Decision to Resident's Representative
Penalty
Summary
The facility failed to provide a written grievance decision to a resident's responsible party after a grievance was filed regarding the resident being found in a soiled gown. The responsible party reported submitting the grievance, and a review of the facility's Grievance/Concern Log confirmed the grievance was filed. During interviews and record reviews, the administrator acknowledged that although the grievance was resolved, there was no documented evidence that a written decision was issued to the responsible party. The facility's policy requires that a written decision be provided at the conclusion of the investigation, including specific details such as the date received, investigative steps, findings, confirmation status, corrective actions, and the date the decision was issued. This omission resulted in a violation of the resident's rights.
Failure to Supervise Resident with Exit-Seeking Behaviors Resulting in Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a known history of attempting to leave the facility unsupervised. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 12, was able to walk 50 feet with minimal assistance and had previously demonstrated exit-seeking behaviors, including leaving the facility and expressing a desire to go to Mexico. Staff interviews confirmed that the resident frequently attempted to leave, set off door alarms, and packed belongings in preparation to exit, with these behaviors occurring approximately every two weeks. Despite these known behaviors, staff did not consistently report the resident's actions to nursing staff as required. On the date of the incident, the resident was discovered missing during a staff lunch break, and after a search of the facility, the police were notified. The resident was subsequently found by police next to a neighboring church. Review of facility policy indicated that residents at risk for elopement should be assessed and have person-centered interventions implemented and communicated to staff, with ongoing monitoring by charge nurses and unit managers. However, the lack of timely reporting and intervention allowed the resident to elope without staff knowledge, resulting in a deficiency related to supervision and accident prevention.
Failure to Address and Document Low Blood Pressure in Resident
Penalty
Summary
Facility staff failed to address a resident's change in condition when the resident repeatedly presented with low blood pressure readings following dialysis treatments. The resident and a family member reported that after returning from dialysis, the resident often felt unwell and requested blood pressure checks, which consistently showed readings below the normal range. Despite these findings, there was no documentation of interventions or physician notification in the resident's medical record, as confirmed by the Director of Staff Development. The facility's grievance log also indicated the resident was dissatisfied with how blood pressure checks were conducted by a CNA. Review of the resident's orders showed no current medication for low blood pressure, and interviews with staff confirmed that the physician should have been notified for systolic blood pressure readings below 100 mm Hg. The facility's policy required nurses to notify the attending physician and document any significant changes in a resident's condition, but this was not done in this case. The lack of intervention and documentation for the resident's persistently low blood pressure constituted a failure to meet professional standards of quality.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for two residents, resulting in both having untrimmed fingernails and dark brown debris under their nails. During observations and interviews, it was noted that the nail care, which was supposed to be performed on Sundays, was not completed for these residents. Certified Nursing Assistants (CNAs) acknowledged the oversight, stating that the residents' nails should have been cleaned and trimmed the previous day. Further interviews revealed that one of the residents was diabetic, and according to the facility's policy, only licensed nurses are responsible for trimming or filing the fingernails of diabetic residents. A Licensed Vocational Nurse (LVN) admitted that nail care was not provided to the diabetic resident on the scheduled day. The facility's policy indicated that routine nail care should be part of the Activities of Daily Living (ADL) care and performed on a regular schedule, which was not adhered to in this instance.
Failure to Schedule RN for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled and on duty for eight hours a day, seven days a week, as required by their policy. During an interview and record review with the Human Resource Payroll Manager, it was revealed that on specific dates in November 2024, namely the 9th, 23rd, and 24th, there was no RN present in the building for the required duration. This was confirmed by the facility's staff schedule and acknowledged by the HR manager. The facility's policy, titled 'Nursing Services-Registered Nurse (RN),' mandates the utilization of RN services for at least eight consecutive hours per day, seven days a week, which was not adhered to on the mentioned dates.
Failure to Conduct Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete Performance Evaluations (PEs) for three of eight sampled employees, specifically Certified Nursing Assistants (CNAs) 54, 88, and a terminated CNA. This deficiency was identified during interviews and record reviews conducted on December 5, 2024, with the Human Resources Payroll (HR) department. CNA 54, hired on June 22, 2021, and CNA 88, hired on April 5, 2022, both had no PEs in their files, as confirmed by HR. Similarly, the terminated CNA, hired on June 11, 2023, also lacked a PE in her file. The facility's policy and procedure for the evaluation process indicated that the HR department should notify department managers of upcoming evaluations, and managers or supervisors should inform employees of their evaluations at least one week prior to the due date. However, this process was not followed, leading to the absence of PEs for the mentioned CNAs.
Inadequate Communication Leads to Improper Food Storage
Penalty
Summary
The facility failed to ensure adequate communication between the Dietary Manager and the Registered Dietitian regarding the malfunction of a refrigerator used to store Time Temperature Control for Safety (TCS) foods. On observation, Refrigerator 1, located in the kitchen, was found to be not in good working condition, with an internal thermometer reading 38 degrees Fahrenheit, but the actual temperature of stored pudding cups was between 50.1 and 52 degrees Fahrenheit. The issue was first identified on 11/29/24, but the refrigerator continued to be used to store TCS foods, which were not maintained at the required temperature of 41 degrees Fahrenheit or less. The Lead Cook noted the problem with the refrigerator and reported it to the Plant Operations Manager on the same day. However, the Dietary Manager was not informed until 12/1/24, and the Registered Dietitian was not aware of the issue until 12/2/24. The Administrator received a text about the refrigerator needing a new compressor but did not communicate this to the Dietary Manager or the Registered Dietitian to ensure proper oversight of food safety. As a result, TCS foods continued to be stored in the malfunctioning refrigerator, posing a risk of bacterial growth due to improper temperature control. The facility's policy and procedure on sanitation require correct temperatures for food storage and handling, which was not adhered to in this case. The Food and Drug Administration (FDA) Food Code recommends that TCS foods be stored at a maximum temperature of 41 degrees Fahrenheit. Despite these guidelines, the facility failed to maintain the required standards, leading to the potential for residents' nutritional needs not being met safely.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. There was an extensive amount of dry old egg debris on the stove range area, and a #8 scooper with dry old food debris was stored inside the clean utensil drawer. The Dietary Manager acknowledged that the scooper should not have been stored with clean utensils, as it was unsanitary. The facility's policy indicated that all utensils should be kept clean, and all equipment used in food handling should be cleaned and sanitized to prevent contamination. The facility also failed to use pasteurized eggs as required by their policy. Observations revealed a case of shelled eggs in the refrigerator that were not labeled as pasteurized, and staff confirmed that the eggs were not pasteurized. The facility's Food and Service Invoice indicated that the supply of eggs was not pasteurized, and meal tray tickets showed that residents were served eggs over easy, which should have been made with pasteurized eggs according to the facility's policy. Additionally, a Certified Nursing Assistant was observed carrying an uncovered salad and dressing down the hallway to a resident's room, contrary to the facility's policy that required food to be covered during delivery. Furthermore, the facility failed to maintain the cold food storage refrigerator at the required temperature. The refrigerator's internal temperature was found to be above the safe range, with pudding cups measuring 50.1 and 52 degrees Fahrenheit. The Plant Operations Manager confirmed that the refrigerator's compressor needed replacement, and the facility's policy required monitoring of food temperature and refrigeration equipment to ensure safe storage conditions.
Failure to Conduct Timely Smoking Assessments
Penalty
Summary
The facility failed to ensure timely completion of smoking assessments for two residents, Resident 13 and Resident 22, which resulted in a lack of assessment for safety while smoking. Resident 13 was admitted on an unspecified date, and no quarterly smoking assessments were completed after September 13, 2023, despite the requirement for assessments on June 5, 2023, December 6, 2023, March 6, 2024, and September 6, 2024. Similarly, Resident 22, admitted on May 1, 2022, did not have quarterly smoking assessments completed after September 13, 2023, although assessments were due in December 2023, March 2024, and June 2024. The facility's policy required smoking assessments during the admission process and each quarterly or comprehensive MDS assessment process to determine the need for supervision or safety in smoking. The failure to conduct these assessments posed a potential risk of residents being burned while smoking.
Medication Administration Error Due to Incorrect Route
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, as evidenced by five medication errors observed out of 43 medication administration opportunities, resulting in an error rate of 11.63 percent. During an observation, a Licensed Vocational Nurse (LVN) administered medications to a resident orally, despite the resident's orders indicating that the medications should be given via a gastrostomy tube (G-tube). The medications involved included chewable aspirin, docusate sodium, metformin, Keppra, and Januvia, all of which were crushed and mixed with pudding before being administered orally. The LVN acknowledged during interviews that the medications should have been administered via G-tube as per the resident's Order Summary Report. The facility's policy and procedure for medication administration, dated January 2024, requires that medications be administered as ordered by the physician and in accordance with professional standards of practice, including verifying the right route of administration. The LVN admitted to not checking the order and failing to contact the physician to change the route of administration prior to giving the medications orally.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for five residents with indwelling devices, which are necessary to prevent the transmission of bacteria. Observations revealed that these residents did not have the required signage or Personal Protective Equipment (PPE) carts outside their rooms, indicating a lack of compliance with infection control protocols. Interviews with staff, including Licensed Vocational Nurses and a Certified Nursing Assistant, highlighted a lack of awareness and understanding regarding the necessity of Enhanced Barrier Precautions for residents with indwelling devices. The facility's policy on Enhanced Barrier Precautions, dated January 2024, mandates that all staff receive training on these precautions and that orders for such precautions be obtained for residents with indwelling medical devices. Despite this policy, the facility did not ensure that the necessary precautions were in place for residents with devices such as Foley catheters and dialysis catheters. The Order Summary Reports for the affected residents indicated the need for regular checks for signs and symptoms of infection, yet the absence of Enhanced Barrier Precautions suggests a failure in policy implementation and staff training.
Failure to Ensure Accurate Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure accurate informed consent for a psychotropic medication for one resident. The resident, who had a severe cognitive impairment with a BIMS score of 2, signed their own informed consent for Zoloft medication. The facility's policy requires a higher cognitive score for a resident to sign their own consent. The Director of Nursing acknowledged that the resident should not have signed the consent due to their cognitive impairment. The facility's policy on informed consent for psychotherapeutic medications emphasizes the need to assess the resident's decision-making capacity, which was not adhered to in this case.
Failure to Maintain Resident Dignity and Personal Care
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident, identified as Resident 10, by not ensuring proper personal care and the availability of personal possessions. Resident 10, who was admitted with diagnoses of schizophrenia and dementia, exhibited moderate cognitive impairment and required partial assistance with personal care tasks. Observations revealed that Resident 10's room was cluttered, her hair was greasy and disheveled, and she emitted a strong smell of urine. Over several days, Resident 10 was observed wearing the same clothes, which were dirty, and she had no clothes or shoes in her closet. Staff interviews indicated that Resident 10 was often left to perform her own personal care, resulting in her unkempt appearance and odor. The facility's policy on resident personal belongings was not adhered to, as Resident 10's personal effects were not maintained in an orderly fashion, and her clothing was reportedly thrown out with the trash by accident. The facility's policy also stated that residents should have at least two sets of clothes, which was not the case for Resident 10. Staff members, including a CNA and the Administrator, acknowledged the lack of clothing and personal care for Resident 10, with the CNA attempting to provide clothing from her own resources. The facility's failure to support Resident 10's right to retain and use personal possessions and to provide necessary personal care compromised her dignity and respect, as outlined in the facility's policies on resident rights and personal belongings.
Failure to Accommodate Resident's Mobility Needs
Penalty
Summary
The facility failed to accommodate a resident's choice to get out of bed daily, which impacted their ability to participate in group activities. The resident, who has impairments in both lower extremities and is dependent on care, expressed a desire to attend activities but was unable to do so due to the unavailability of a Geri-chair, which is necessary for their mobility. Despite the resident's interest in activities such as bingo, nails, and coloring, and their need for assistance to attend these activities, the facility did not provide the necessary equipment consistently. Interviews and record reviews revealed that the resident had not participated in any group activities for the months of November and December, as the facility only had three Geri-chairs, all of which were in use by other residents. The Interim Director of Activities confirmed the lack of participation and the absence of a schedule for Geri-chair use among dependent residents. Observations showed that a Geri-chair was not in use in one room, indicating a potential oversight in resource allocation. The facility's policies emphasize promoting resident self-determination and accommodating individual needs, but these were not adhered to in this case.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Responsible Party (RP) for a resident when there was a change in the resident's condition that required admission to an acute care hospital. During a review of the resident's Change in Condition Evaluation (COC) on two separate occasions, it was noted that the resident was unresponsive and transferred to the hospital by Emergency Medical Technicians (EMT). The COC indicated that the resident was their own RP, but the Director of Nursing (DON) confirmed that no family was notified, although they should have been. The facility's policy and procedure on Notification of Changes requires informing the resident, consulting with the resident's physician, and notifying the resident's family or legal representative when there is a significant change, such as a transfer or discharge from the facility.
Failure to Provide and Complete Advanced Beneficiary Notices
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to one resident and failed to accurately complete the ABN for another resident. In the first case, Resident 192 was not given the ABN after self-discharging from Medicare Part A before exhausting benefit days and remaining in the facility. The Admissions Coordinator (AC) acknowledged that the ABN should have been provided alongside the Notice of Medicare Non-Coverage (NOMNC), which was issued when the resident requested to be taken off occupational therapy. In the second case, Resident 195's ABN was left incomplete as none of the required option boxes were checked, although the resident had signed the form. The AC confirmed that one of the boxes needed to be checked for the form to be considered complete. The facility's instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) specify that the patient must select one option and sign the form to acknowledge understanding. Failure to complete the form correctly could result in the notice being invalidated and the facility being held liable for the care in question.
Failure to Complete PASRR Level II Evaluations
Penalty
Summary
The facility failed to accurately complete the annual pre-admission screening assessment and resident review (PASRR) for two residents, which is a federal requirement to ensure individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting. Resident 13's PASRR Level I Screening indicated a positive result for Serious Mental Illness (SMI) but negative for Intellectual Disability (ID), Developmental Disability (DD), and Related Condition (RC). However, there was no Level II PASRR performed on Resident 13, as confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident 42's PASRR Level I Screening also indicated a positive result for SMI and negative for ID/DD/RC, yet no Level II PASRR was conducted. The DON acknowledged that a Level II screening should have been performed for Resident 42. The facility's policy and procedure on Resident Assessment - Coordination with PASARR program, dated January 2024, states that a positive Level I screen necessitates a PASARR Level II evaluation prior to admission, and if a resident remains in the facility longer than 30 days, a Level II resident review must be completed within 40 calendar days of admission.
Failure to Obtain Diet Order Upon Admission
Penalty
Summary
The facility failed to obtain a diet order upon admission for a resident, which had the potential to result in unmet nutritional needs. Upon reviewing the resident's Admission Record, it was found that the resident was admitted without a diet order. The Order Summary Report, dated four days after admission, indicated a controlled carbohydrate diet with thin pureed texture and thin consistency was ordered by the facility's physician. This was the first diet order documented for the resident. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that there was no documentation of a physician-ordered diet upon the resident's admission. The ADON acknowledged that the nurse should have contacted the physician to obtain the diet order. The facility's policy and procedure on Admission Orders requires that a physician or other qualified healthcare professional provide written or verbal orders for residents' immediate care, including dietary needs. The facility's policy on Diet Orders specifies that diet orders prescribed by the physician should be communicated to the Food & Nutrition Services Department.
Failure to Provide Hearing Services to Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident, identified as Resident 10, to improve her hearing and communication needs. Upon review of Resident 10's Admission Record, it was noted that she was admitted on an unspecified date. During an observation and interview, it was evident that Resident 10 had difficulty hearing, requiring the surveyor to speak loudly and clearly near her ear. Resident 10 expressed a desire for hearing aids to improve her ability to hear. Further interviews revealed that the Social Service Designee (SSD) was unaware if audiology services had been utilized for Resident 10, despite acknowledging her hearing difficulties. It was confirmed that Resident 10 had never undergone a hearing test at the facility. The facility's policy and procedure on Hearing and Vision Services mandates that residents have access to necessary services and adaptive equipment, with the social worker or SSD responsible for assisting residents in obtaining these resources. However, this policy was not followed, resulting in Resident 10's communication needs not being met.
Failure to Document Nutritional Supplement Intake
Penalty
Summary
The facility failed to document the quantity consumed of a nutritional beverage supplement for a resident who experienced significant weight loss. During an observation, it was noted that the resident had an unopened carton of a health shake on her meal tray, which she did not consume because she disliked it. The resident expressed concern about her rapid weight loss. Interviews with CNAs revealed that the facility's documentation system did not itemize fluid intake, making it unclear whether the health shake was consumed. The Registered Dietitian (RD) confirmed that the lack of documentation hindered accurate nutrition assessments and the ability to monitor the effectiveness of nutritional interventions. Further review of the resident's records showed that the Medication Administration Record (MAR) only indicated that the health shake was provided, without documenting the quantity consumed. The Assistant Director of Nursing (ADON) acknowledged the absence of a system to document the quantity consumed of nutritional supplements. The facility's policy stated that residents' nutritional needs should be assessed and reassessed periodically, but the lack of documentation prevented effective monitoring and timely intervention to address the resident's nutritional needs.
Improper Handling and Disposal of Controlled Medication
Penalty
Summary
A Licensed Vocational Nurse (LVN 2) failed to ensure the security and proper disposal of a controlled medication during a medication pass. While administering medications to a resident, LVN 2 dropped a plastic medication cup containing multiple medications, including Tramadol, a controlled substance, onto the bed. LVN 2 acknowledged that the dropped medications needed to be wasted and required a witness to sign off on the wasted Tramadol. However, LVN 2 placed the medication cup on top of the medication cart and left it unattended while entering the resident's room, which was against the facility's policy that requires medications to be under direct observation or locked away. Additionally, LVN 2 improperly disposed of the controlled medication. After obtaining a witness, LVN 2 disposed of the Tramadol and other medications in a black plastic container labeled as a Hazardous Waste Container without crushing the tablets or using a solvent to destroy them. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the black bins were not appropriate for controlled medication disposal and that such medications should be destroyed using a drug buster liquid or brought to the DON's office for destruction with a pharmacist. The facility's policy requires that the destruction of drugs be witnessed by a consultant pharmacist and another designated individual, which was not followed in this instance.
Failure to Follow Meal Tray Tickets and Planned Menus
Penalty
Summary
The facility failed to adhere to the meal tray ticket and planned menu for two residents, potentially impacting their nutritional goals. During an observation and interview with the Registered Dietitian (RD), it was noted that Resident 62's lunch meal tray, which was supposed to include large portions, only had one slice of garlic bread instead of the two slices indicated on the meal tray ticket. This discrepancy was confirmed by the RD, who stated that two slices should have been served per the planned menu for a large portion diet. Additionally, Resident 83's meal tray was missing the 4 oz of 2% milk as indicated under standing orders on the meal tray ticket. The facility's policy and procedure for diet orders, dated 2023, requires that diet orders prescribed by the physician be provided by the Food & Nutrition Services Department, with nursing responsible for sending a Diet Order Communication slip to the department.
Failure to Serve Correct Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a therapeutic diet was served in accordance with the diet order for one resident, identified as Resident 22. During an observation and record review, it was noted that Resident 22 received a meal tray with regular texture food, including cornbread and chili, despite having a physician's diet order for a pureed texture diet. The meal ticket initially indicated a regular texture diet, but a handwritten notation had replaced 'thin liquid' with 'puree.' However, the resident was still served the incorrect diet. The Registered Dietitian confirmed that there were two meal tray tickets on file for Resident 22, one indicating a regular texture diet and the other a pureed diet, and acknowledged that the resident was not provided the correct physician-ordered therapeutic diet of pureed texture. The facility's policy and procedure required that diet orders prescribed by the physician be provided by the Food & Nutrition Services Department, with nursing responsible for sending a Diet Order Communication slip to the department.
Failure to Label and Date Food in Resident Refrigerator
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'FOOD FOR RESIDENTS FROM OUTSIDE SOURCES' concerning the storage of food brought in by family and visitors. During an observation and interview, it was noted that the resident designated refrigerator (RDR) contained undated and unlabeled foil-covered plated food items. Certified Nursing Assistant (CNA) 81 confirmed that all food stored in the RDR should have been dated and labeled with the resident's name. Licensed Vocational Nurse (LVN) 5 also stated that food stored in the RDR should include the resident's name and the date the food item was received. The facility's policy indicated that prepared foods requiring refrigeration should be sealed, dated, and disposed of within two days after opening, which was not followed in this instance.
CNA Uses Profanity During Resident Care
Penalty
Summary
The facility failed to ensure that staff treated a resident with respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) using profanity while providing care. The incident was documented in a Report of Suspected Dependent Adult/Elder Abuse, which indicated verbal aggression by CNA 1. The resident involved, who had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 05, was subjected to verbal abuse when CNA 1 used profanity during care. This was corroborated by an SBAR document noting that staff overheard CNA 1 yelling at the resident, and by interviews with other staff and the resident's roommate. CNA 2, who overheard the incident, confirmed that CNA 1 was shouting and using profanity towards the resident. The Assistant Administrator also confirmed that CNA 1 admitted to using profanity, acknowledging it as verbal abuse. The resident's roommate further described CNA 1's frustration and disrespectful behavior during care. CNA 1 admitted to becoming frustrated and using inappropriate language, recognizing it as verbal abuse. The facility's policy on Resident Rights, which emphasizes the right to be treated with respect and dignity, was not adhered to in this instance.
Failure to Verify Employment References for CNA
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding employment reference checks, which had the potential to put residents at risk for abuse. Specifically, the facility did not verify all employment references for a Certified Nursing Assistant (CNA 1) before hiring. CNA 1's Application for Employment listed two previous employers and three personal references. However, during the review of CNA 1's Pre-Employment Reference Check, it was found that only one of the employment references and two personal references were verified. The employment reference for the second previous employer, Facility 3, was not verified. The Director of Staff Development acknowledged this oversight, and the Assistant Administrator confirmed that both employment references should have been verified before personal references. The facility's policy, revised in January 2024, mandates that the human resources department must verify the certification status of applicants with the nurse aide registry of the state where they are certified or previously employed.
Failure to Notify Responsible Party of Resident's Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's condition, specifically redness to the bilateral buttocks, upon the resident's admission. The resident was admitted with this condition, but there was no evidence in the progress notes that the RP was informed. During an interview, the RP confirmed that they were not notified about the redness. Additionally, a Licensed Vocational Nurse (LVN) reviewed the medical record and confirmed the lack of notification. The Director of Nursing (DON) also reviewed the medical record and acknowledged the absence of documentation regarding the notification of the RP. The facility was unable to provide a policy and procedure for RP notification when requested.
Resident's Dignity Violated by Inappropriate Staff Comment
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, resulting in a violation of the resident's rights. The incident involved a Certified Nursing Assistant (CNA) making an inappropriate comment while providing care to the resident. During the provision of care, the resident requested a pillow, and CNA 2 made a derogatory remark about the resident's condition, referring to it as a 'stinky butt.' This comment was overheard by the resident, who found it disrespectful and reported it to the Director of Nursing (DON). Interviews with the involved staff confirmed the incident. CNA 1 acknowledged that CNA 2 made the comment in a joking manner, but recognized it was inappropriate. CNA 2 admitted to making the comment and apologized, acknowledging it was not suitable. The facility's Administrator also confirmed that the comment was against the facility's policy on resident rights, which mandates treating residents with respect and dignity. The facility's policy review further supported that the resident has a right to be treated with respect and dignity.
Failure to Provide In-Service Training for CNA After Allegation
Penalty
Summary
The facility failed to provide in-service training for a Certified Nursing Assistant (CNA 1) before she returned to work, following an allegation of rushed care and a bad attitude towards a resident. The incident was reported by the resident's family, who noted that the care provided by CNA 1 and another CNA (CNA 2) was rushed. The Director of Nurses (DON) was informed of the resident's dissatisfaction on the same day the incident was reported. Despite instructions from the Administrator to provide in-service training to both CNAs, the Director of Staff Development (DSD) was unaware that CNA 1 had returned to work and did not provide the necessary training. CNA 1 returned to work on three separate days without receiving the in-service training, which she acknowledged she needed to understand and correct her actions. The DON assumed that the DSD had conducted the training, but it was confirmed that this had not occurred. Additionally, the facility lacked a policy on in-service training, which contributed to the oversight. This failure had the potential to allow CNA 1 to continue providing care with a bad attitude and in a rushed manner, as alleged by the resident.
Failure to Notify Physician of Missed Medications
Penalty
Summary
The facility failed to ensure that a physician was notified when a resident did not receive prescribed medications as ordered. Specifically, a resident was prescribed Lovenox, a blood thinner, to be administered daily for 30 days to prevent blood clots due to a fracture. However, the medication was not administered on multiple days throughout May 2024, as it was not available. Despite this, there was no documentation indicating that the physician was informed of the missed doses. Licensed Vocational Nurse (LVN) 1 confirmed the absence of such documentation and acknowledged that the physician should have been notified. Additionally, the same resident was prescribed Depakote for bipolar disorder, which was not administered on one occasion due to the medication being unavailable. Again, there was no documentation showing that the physician was notified of the missed dose. Both LVN 1 and the Director of Nursing (DON) confirmed that the physician should have been informed when medications were unavailable. The facility's administrator was unable to provide a policy regarding the notification of physicians in such situations.
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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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